SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 220 Main Street, Brawley, CA 92227 415 East Fourth Street, Calexico, CA 92231 939 West Main Street, El Centro, CA 92243 1625 West Main Street, El Centro, CA 92243 2124 Winterhaven Drive, Winterhaven, CA 92283 DEFENDANT: FOR COURT USE ONLY REQUEST FOR EXTENSION TO PAY CASE NUMBER: PLEASE DATE, SIGN, AND MAIL ORIGINAL DOCUMENT TO COURT Advisement of Rights By choosing to pay and forfeit bail in installments and not go into court, you will be giving up these rights: To appear in court for formal arraignment, plea and sentencing; To have a court trial and challenge the charges; To have a speedy court trial and have the charges dismissed if a speedy trial is requested but not provided; To be represented by an attorney at your expense; To subpoena and present witnesses and physical evidence using the power of the court at no cost to you and testify on your own behalf; To confront and cross-examine all witnesses under oath testifying against you; and To remain silent and not testify. Initial each line below that you are agreeing to: ____ I have read and give up those rights listed on the advisement above. ____ I wish to forfeit the bail amount by paying within 90 days of this agreement, which is the equivalent of a plea of guilty and a conviction that will be placed on my driving record. I, the undersigned, agree to make payments on this case and I promise to pay the FULL fine amount of $______________ by _____________. Amount due Date If not paid timely, a $30.00 administrative fee will be added to the fine balance. Failure to pay the fine as indicated above may result in the following: A Civil Assessment in the amount of $300.00 pursuant to Penal Code 1214.1 VC40508.5 Civil Assessment is enforced as a civil judgment, including but not limited to wage garnishments, tax intercepts and liens on property. DMV will be notified pursuant to VC40509.5 immediately to suspend your driving privilege pursuant to VC13365(a)(2). This suspension will not be lifted until all fines/fees are paid in full. Date: ________________________ Signature: _________________________________________ Adopted for Mandatory Use CR-12 (Adopted 01/01/13) REQUEST FOR EXTENSION TO PAY American LegalNet, Inc. www.FormsWorkFlow.com