SUPERIOR COURT OF THE STATE OF CALIFORNIA COUNTY OF IMPERIAL REQUEST TO VACATE CIVIL ASSESSMENT (PC1214.1(b)) Defendant’s Name: ___________________ Case Number: ____________________________ You have failed to pay your fine. This Court will order you to pay a civil assessment of $300.00 in addition to your original fine unless good cause is shown for your failure to pay. If you have good cause to excuse your failure to pay, complete the information below. Written proof of any of the following must be attached and cover the time period in question. [ ] Hospitalization [ ] Incarceration [ ] Overseas Military Duty [ ] Other The following is an explanation for my failure to pay or appear: In addition, proof that the original fine balance is paid in full must be attached to this request. I declare under penalty of perjury that the above is true and correct to the best of my knowledge. Executed at _______________________(city), California on ______________________(date) Name (print) ______________________Area Code/Telephone #_______________________ Address, City, State, Zip ________________________________________________________ Signature of Defendant: _____________________________________  Staff review: ___________________________________ Date: ______________________ ORDER RE: VACATING CIVIL ASSESSMENT (COURT USE ONLY) The Court having read and considered the Petition and evidence regarding vacating the Civil Assessment pursuant to PC 1214.1(B), hereby makes the following order. Judgment on the charge(s) will not be set aside. Request to vacate is: [ ] Granted [ ] Denied ___________________________________ Signature of Judicial Officer _____________________________ Date Form Approved for Mandatory Use Col-01 (Adopted 01/01/10) American LegalNet, Inc. www.FormsWorkFlow.com