Request for Ability to Pay Determination If you are getting public benefits, are a low-income person, or do not have enough income to pay for your household's basic needs and your traffic court fines and fees, you may use this form to ask the court to consider your ability to pay. The court may order you to answer questions about your finances. If the court reduces your outstanding fines, you may still have to pay later if: You cannot give the court proof of your eligibility Your financial situation improves during the duration of your payment plan CONFIDENTIAL Clerk stamps date here when form is filed. Fill in court name and street address: Your Information (person making request of court): Name: _____________________________________________________ Street or mailing address: ______________________________________ City: __________________________State: _____ ZIP: ______________ Phone number: ______________________________________________ Superior Court of California, County of Amador 500 ARGONAUT LANE JACKSON, CA 95642 Your job, if you have one (job title): Name of employer: ___________________________________________ Employer's address: __________________________________________ Why are you asking the court to consider your ability to pay? A. Case number(s): I receive (check all that apply, see Judicial Council form FW-001-INFO for definitions): Food Stamps Supp. Sec. Inc. General Asst. IHSS CalWORKS or TANF CAPI B. My gross monthly household income (before deductions from taxes) is not more than the amount listed below: (If checked, you must complete questions 6, 7, and 8 on page 2 of this form.) Family Income $1,237.50 $1,668.75 Family Size 3 4 Family Income $2,100.00 $2,531.25 Family Size 5 6 Family Income $2,962.50 $3,393.75 1 2 If more than 6 people at home, add $433.34 for each extra person Family Size C. I do not have enough income to pay for my household's basic needs and the court fines. (If checked, you must fill out page 2 of this form.) I ask the court to: Reduce the total amount of fines that I owe Let me make payments over time Allow me to perform community service in lieu of paying the fine If you asked the court to let you make payments over time, what is the amount you could afford to pay each month? ___________________ Check here if you asked the court to consider your ability to pay on this matter in the last six months. (If you can access your previous request, please attach it to this form and check here.) I declare under penalty of perjury under the laws of the State of California that the information I have provided on this form is true and correct. Date: ________________________________ ______________________________________ Sign here American LegalNet, Inc. www.FormsWorkFlow.com AMADOR SUPERIOR COURT Page 1 of 2 Form approved for optional use TRF-325 (NEW 02/2017) REQUEST FOR ABILITY TO PAY DETERMINATION Case Number(s): Your Name: If you checked 3a on page 1, do not fill out below. If you checked 3b, fill out questions 6, 7, and 8 only. If you checked 3c, you must fill out this entire page. If you need more space, attach a sheet of paper and write Financial Information and your name and case number at the top. Check here if your income changes a lot from month to month. If it does, complete the form based on your average income for the past 12 months. Your Money and Property a. Cash $ Your Gross Monthly Income a. List the source and the amount of any income you get each month, including: wages or other income from work before deductions, spousal/child support, retirement, social security, disability, unemployment, military basic allowance for quarters (BAQ), veterans payments, dividends, interest, trust income, annuities, net business or rental income, reimbursement for jobrelated expenses, gambling or lottery winnings, etc. (1) $ (2) $ (3) $ (4) $ b. All financial accounts (list bank name and amount): (1) $ (2) $ (3) $ (4) $ c. Cars, boats, and other vehicles: Make / Year (1) (2) (3) (4) d. Real estate: $ $ $ $ Fair Market Value $ $ $ $ Fair Market Value $ $ $ $ How Much You Still Owe How Much You Still Owe b. Your total monthly income: $ Address (1) (2) Household Income a. List the income of all other persons living in your home who depend in whole or in part on you for support, or on whom you depend in in whole or in part for support. Name (1) (2) (3) (4) Age Relationship $ $ $ $ Gross Monthly Income e. Other personal property (jewelry, furniture, furs, stocks, bonds, etc.: Fair Market How Much You Describe Value Still Owe (1) $ $ (2) $ $ Your Monthly Deductions and Expenses a. List any payroll deductions and the monthly amount below: (1) $ (2) $ (3) $ (4) $ b. Rent or house payment & maintenance $ c. Food and household supplies d. Utilities and telephone e. Clothing f. Laundry and cleaning g. Medical and dental expenses h. Insurance (life, health, accident, etc.) i. School, child care j. Child, spousal support (another marriage) k. Transportation, gas, auto repair, insurance l. Installment payments (list each below): Paid to: (1) (2) (3) $ $ $ $ $ $ $ $ $ $ $ $ $ b. Total monthly income of persons above: $ Total monthly income and Household income (7b plus 8b) $ _____________ To list any other facts you want the court to know, such as unusual medical expenses, etc., attach a sheet of paper and write Financial Information and your name and case number at the top. Check here if you attach another page. Important! If your financial situation or ability to pay court fees improves, you must notify the court within five days using Judicial Council form FW-010. Form approved for optional use TR-325 (NEW 02/2017) m.Wages/earnings withheld by court order n. Any other monthly expenses (list each below): Paid to: How Much? (1) $ (2) $ (3) $ Total Monthly Expenses (add 10a­10n above): $ ____________ AMADOR SUPERIOR COURT Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR ABILITY TO PAY DETERMINATION