TR-105RC Petition For Consideration re Ability to Pay CONFIDENTIAL Clerk stamps date here when form is filed. Note: You MUST complete pages 1 and 2 of this form You may file this request if you have a financial hardship and can show that you are unable to pay the full amount for the offense(s) on your case, you may request the Court to consider your ability to pay in setting the fine amount. Also, if you are ordered to pay a fine you may ask the Court for an installment payment plan that is based on your ability to pay, or ask the Court to approve community service or alternative to paying the fine due to financial hardship. However, you must appear before the Court to do so. This form should be completed when you appear in court. You may be asked to provide financial documentation in support of your request. Fill in court name and street address: 1 Your Information: Name: Street or mailing address: City: Phone number: Your Job, if you have one (job title): Employer's address: Name of employer: Fill in case number and name: Case Number: State: ZIP: Case Name: 2 3 Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number): a. The lawyer has agreed to represent you without charging fees or costs (check one): Yes b. (If yes, your lawyer must sign here): Lawyer's signature: If no, and your lawyer is not providing legal-aid type services based on your low income, please explain below and on page 2. 4 I am requesting consideration of the Court on this case based on my "ability to pay determination". a. I receive (check all that apply): Medi-Cal Food Stamps SSI SSP No County Relief/ General Assistance IHSS (In-Home Supportive Services) CalWORKS or Tribal TANF (Tribal Temporary Assistance for Needy Families) CAPI (Cash Assistance Program for Aged, Blind and Disabled) b. My gross monthly household income (before deductions for taxes) is less than the amount listed below. Family Size 3 4 Family Income $2,100.00 $2,531.25 Family Size 5 6 Family Income $2,962.50 $3,393.75 If more than 6 people at home, add $433.34 for each extra person. Family Size Family Income 1 2 $1,237.50 $1,688.75 c. I do not have enough income or available credit to pay for my household's basic needs. (Explain): PTR-105RC E08-16 Petition For Consideration re Ability to Pay Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Your name: You must fill out this entire page. I declare under penalty of perjury under the laws of the State of California that the information I have provided on this form and all attachments is true and correct. Date: /S/ Print your name here Sign here 5 Check here if your income changes a lot from month to month. Fill out below based on your average income for the past 12 months. 8 6 Your Monthly Income a. Gross monthly income (before deductions): List each payroll deduction and amount below: (1) (2) (3) (4) Your Money, Assets, and Property a. Cash $ b. All financial and credit accounts (List bank and available balance): (1) $ $ $ $ How Much You Still Owe $ $ $ Fair Market Value $ $ $ $ $ $ How Much You Still Owe $ $ $ $ $ (2) (3) (4) c. Cars, boats, and other vehicles Make / Year (1) (2) (3) $ b. Total deductions (add 8a (1)-(4) above): c. Total monthly take-home pay (8a minus 8b): $ d. List the source and amount of any other income you get each month, including: 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 job-related expenses, gambling or lottery winnings, etc. (1) (2) (3) (4) Fair Market Value $ $ $ d. Real estate Address (1) (2) (3) $ $ $ $ $ e. Other personal property (stocks, bonds, jewelry, furniture, collectables, antiques, art, etc.): Describe (1) (2) (3) Fair Market Value $ $ $ $ $ $ How Much You Still Owe e. Your total monthly income is (8c plus 8d): 7 Household Income a. List all other persons living in your home and their income; include only your spouse and all individuals who depend in whole or in part on you for support, or on whom you depend in whole or in part for support. Gross Monthly Age Relationship Income Name (1) $ (2) (3) (4) 9 Your Monthly Expenses (Do not include payroll deductions you already listed in 8b.) $ $ $ b. Total monthly income of persons above: Total monthly income and household income (8e plus 9b): $ a. b. c. d. e. f. g. h. i. j. k. $ Rent or house payment & maintenance $ Food and household supplies $ Utilities and telephone $ Clothing $ Laundry and cleaning $ Medical and dental expenses $ Insurance (life, health, accident, etc.) $ School, child care $ Child, spousal support (another marriage) $ Transportation, gas, auto repair and insurance $ Installment payments (list each below): Paid to: How Much? $ (1) (2) (3) $ $ $ l. Wages/earnings withheld by court order PTR-105RC E08-16 Petition For Consideration re Ability to Pay Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Your name: 9 Your Monthly Expenses (cont.) m. Any other monthly expenses (list each below). $ Paid to: (1) (2) (3) How Much? $ $ $ To list any other facts you want the Court to know, such as unusual medical expenses, family emergencies, etc., attach form MC-025. Or 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. Total monthly expenses (add 11a ­11m above): $ /S/ Signature For Judicial Use Granted Balance of Fine and or Fees Suspended Community Service hours to be complete through by Denied Driver license hold remains based on the ability to pay determination The Court orders: Installment payments of $ per month beginning with additional $35.00 installment plan fee Fine modified to / by $ due forthwith. Fine modified to / by and payable in full by with additional $30.00 time to pay fee Fine modified to / by and payable in full by with additional $30.00 time to pay fee Fine modified to / by , payable in installments of per month beginning with additional $30.00 time to pay fee Case recalled from GC/MSB Collection Agency Driver license hold lifted Court orders: Date: Judge's Signature PTR-105RC E08-16 Petition For Consideration re Ability to Pay Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com