Attorney or Party Without An Attorney (Name, State Bar No. & Address) FOR COURT USE ONLY Telephone No. Attorney for: NAME OF COURT: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO STREET ADDRESS: MAILING ADDRESS: CITY, STATE ZIP: DISTRICT NAME: PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT: REQUEST TO ADDRESS CIVIL ASSESSMENT FOR FAILURE TO APPEAR/PAY PURSUANT TO PC1214.1(a) CASE NUMBER In accordance with Penal Code section 1214.1(a), the Court imposed a Civil Assessment to your case in lieu of issuing a warrant. Note: Only one request to address this civil assessment may be filed. You have the following options to address the Civil Assessment: OPTION 1: Establish Payment arrangements (No court appearance required): You may establish payment arrangements. (If this option is selected, I will be required to pay a $35.00 administrative fee). Please contact the court at the above address or Court Compliance at (909) 387-1470. OPTION 2: Submit a "good cause" statement and attach supporting documents. (Court appearance may be required): You must show good cause (explain in writing the circumstance beyond your control) as to why you failed to appear or pay; and you must attach documentation to support the explanation which includes written proof of the following: A. Medical Incapacitation/Hospitalization. I have attached proof of incapacitation/hospitalization from _____________ to ______________. B. Incarceration. I have attached proof of incarceration from ______________ to ______________. C. Military Orders. I have attached proof of military orders from ______________ to ______________. IMPORTANT: Attach copies only as written proof, originals will not be returned to you. OPTION 3: In the event none of the circumstances in Option 2 apply, submit a "good cause" statement and attach supporting documents. (Court appearance may be required): Good Cause Statement: I failed to appear in court or I had good reason for not paying my fine (other than those reasons listed in option 2) when due. Explain the circumstance/reason that prevented you from responding within the specified time period: I have attached the supporting document(s) from _________________ to ________________. I understand that I may be ordered to appear in court to explain these circumstances. 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 as required. SIGNATURE OF DEFENDANT OTS-CRTIAE-RC-20130904 DATE Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com REQUEST TO ADDRESS CIVIL ASSESSMENT FOR FAILURE TO APPEAR/PAY PURSUANT TO PC1214.1(a) Form #21288 CIVIL ASSESSMENT FOR FAILURE TO APPEAR OR FAILURE TO PAY Instruction and Information Sheet Steps to Resolving Your Civil Assessment Complete the form. "Request to Address Civil Assessment for Failure to Appear or Failure to Pay" (Form # ____) 1. Insert your name, address, phone number and case number 2. Select and complete option 1, 2 or 3 3. Date and sign the Request IMPORTANT: If you select option 2 or 3, you must attach the supporting documents and you must take care of the original violations with which you were charged. Contact the clerk's office at _______________________ if you need assistance. Step 2: Mail or submit your request, along with the supporting documents to the court location listed on your citation. The Court address is as follows: Barstow District; 235 East Mountain View, Barstow, CA 92311 Joshua Tree District; 6527 White Feather Road, Joshua Tree, CA 92252 Rancho Cucamonga District; 8303 N. Haven Ave., Rancho Cucamonga, CA 91730 San Bernardino District; 351 N. Arrowhead Ave., San Bernardino, CA 92415 Victorville District; 14455 Civic Drive, Suite 100, Victorville, CA 92392 Note: Only one request to address this civil assessment may be filed. The court will notify you of the outcome of your request by mail. FREQUENTLY ASKED QUESTIONS: What is a Civil Assessment? A Civil Assessment of $300.00 is imposed on anyone charged with a traffic, misdemeanor or felony offense that (after notice) fails to appear by the scheduled appearance/hearing date and/or fails to pay a court ordered fine by the due date. How is the Civil Assessment imposed? If you fail to appear on a date you are supposed to be in court, a warning notice will be mailed to your last known address. If so mailed, there is a presumption that the notice has been received. There is no requirement that the court prove that you actually received the notice, only that it was mailed. Is there a grace period? If you appear within the 10-day time frame shown in the warning notice and show good cause for not appearing on the date you were supposed to appear, the court may address the assessment. What are the consequences of a civil assessment for a failure to appear or pay a fine? The court will notify the DMV and the DMV may place a hold or suspend your driving privileges until the civil assessment is cleared with the court. Note: If your civil assessment is for a failure to pay, you will be required to pay the fine in full, including the civil assessment amount, in order to get the DMV hold lifted. What if I moved? The Court is under no obligation to try to find your current address. You have an obligation to notify the court while the case is still open of any change of address. Can there be more than one civil assessment added to my case? Yes. It is possible to have a civil assessment added for each missed court appearance. A separate warning notice is required to be sent for each assessment. What is Good Cause? Good Cause is a sufficient reason that is beyond your control (e.g. medical emergency, military duty, etc.), which prevented you from making an appearance or payment on or before the date listed on your citation (ticket) and a demonstration that you attempted to resolve the matter as soon as possible after that date. Good Cause is determined on a case-by-case basis. OTS-CRTIAE-RC-201300904 REQUEST TO ADDRESS CIVIL ASSESSMENT FOR FAILURE TO APPEAR/PAY PURSUANT TO PC1214.1(a) Form #21288 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com