SUPERIOR COURT OF CALIFORNIA, COUNTY OF MENDOCINO Ukiah Branch 100 North State Street Ukiah, CA 95482 (707) 463-4660 Ten Mile Branch 700 South Franklin Street Fort Bragg, CA 95437 (707) 964-3192 CIVIL ASSESSMENT PETITION AND ORDER Defendant's Request and Declaration to Vacate Civil Assessment Defendant's Name: Case Number: IMPORTANT: WRITTEN proof of any of the following MUST be attached and cover the time period in question. HOSPITALIZED OVERSEAS MILITARY DUTY INCARCERATED OTHER The following is an explanation of my failure to pay: (Please type or print) I declare under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge and that written proof is attached to this form. Executed at (City and State) on (date) Address: City State: ZIP: Signature: (Defendant) Telephone: ( ) - ORDER RE CIVIL ASSESSMENT (COURT USE ONLY) The Court having read and considered the Petition regarding vacating the Civil Assessment pursuant to PC § 1214.1(B), hereby makes the following order: Petition to vacate is: Denied Granted Installment Payments are allowed Fine is converted to _________ hours of community service. Signature: ___________________________________________ (Judicial Officer) Date: ________________________________ To the defendant: You must pay $______________ by ______________________. Payment options: Mail ­ send check or money order (no cash) to the address noted at the top of this letter. Phone ­ call (707) 463-6872 to pay by MasterCard or Visa. Internet ­ Visit our website at www.mendocino.courts.ca.gov In person ­ Visit either branch listed at the top of this letter, and pay with cash, check, money order, or credit card. MTR-110-L0CAL (rev 031313) CIVIL ASSESSMENT PETITION AND ORDER Defendant's Request and Declaration to Vacate Civil Assessment American LegalNet, Inc. www.FormsWorkFlow.com