Clerk stamps date here when form is filed. Fill in the case number and ticket number (if you have it): Fill in court name and street address: Street City State Zipwww.courts.ca.gov (optional): * Some courts don't use text messages and email to contact court clients. Message and data rates would apply. (Check that apply, then skip to ) (Skip to ) (specify): www.courts.ca. g ov/sel f help.htm www.courts.ca. g ov/ f ind-m y -court.htm American LegalNet, Inc. www.FormsWorkFlow.com (Answerthat apply) (Check one) Check that apply, if any) (Check one): Basic living expenses are things like: food, utilities, childcare, child support, transportation, medication, insurance (medical, car, house, and rental), and student loans. (please explain): Things like an EBT card, paystubs, tax returns, rent or mortgage checks, or utility bills.Important! Keep the original documents for your own records. Any copies you attach can be destroyed after the court makes a decision on your case. Cross out any social security numbers, or other private information, on the copy you give the court. (Skip to ) (Check that apply, if any.) American LegalNet, Inc. www.FormsWorkFlow.com (Check that you are willing and able to do) (month/day/year) (You can add extra pages or attach other documents that help you explain) Did you miss a court date or fail to pay a fine? If so, the Department of Mortor Vehicles (DMV) might have suspended or put a "hold" on your driver's license. If the court clears your failure to appear or failure to pay, the court can notify the DMV. You must still contact the DMV to get your license back. I declare under penalty of perjury, under the laws of the State of California, that all information on or attached to this form is true. Type or print your nameSign your name 001 American LegalNet, Inc. www.FormsWorkFlow.com