SUPERIOR COURT OF CALIFORNIA COUNTY OF EL DORADO [ ] SOUTH LAKE TAHOE BRANCH 1354 JOHNSON BLVD., STE. 1 SOUTH LAKE TAHOE CA 96150 PHONE: (530) 573-3044 [ ] WEST SLOPE BLDG. C DEPT. 8 - TRAFFIC 2850 FAIRLANE COURT PLACERVILLE CA 95667 PHONE: (530) 621-7470 CASE NUMBER: NAME: PLEA AND WAIVER FOR INFRACTIONS I plead [ ] guilty, or [ ] no contest to the violation of: I understand and voluntarily give up the following rights: (Please initial) [ ] 1. Right to a court trial within 45 days. [ ] 2. Right to counsel (at my own expense.) [ ] 3. Right to remain silent. [ ] 4. Right to confront and cross-examine witnesses. TERMS AND CONDITIONS OF PAYMENT Fine Amount: $ per month starting Pay at the rate of $ It is your responsibility to make monthly payments; no billing statements will be provided. (Please initial) [ ] 1. [ ] 2. [ ] 3. [ ] 4. I understand that failure to make a payment WILL result in increased costs and the case will be referred to collection. I understand that failure to pay by the due date will result in referral to collection and a civil assessment fee of $300.00 will be added to the fine. I understand that if I choose to make monthly payments, a one-time $35.00 Administrative Fee must be paid upon signature of this form. By signing this document I understand the above terms and conditions. SIGNATURE: DATE: Social Security Number: Current Mailing Address: Current Street Address: Employer: Employer's Address: Date: Received by: (Court Clerk) T-010 (revised 9/1/05) American LegalNet, Inc. www.USCourtForms.com