SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 939 W. Main Street El Centro, CA 92243 DEFENDANT: FOR COURT USE ONLY REQUEST TO VACATE CIVIL ASSESSMENT (PC1214.1(b)) 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 [ ] Extenuating Circumstance The following is an explanation for my failure to pay or appear: ______________________________________________________________________________ ______________________________________________________________________________ I declare under penalty of perjury that the above is true and correct to the best of my knowledge. Executed at ________________________________, on __________________________(date) (city, state) Name (print) ______________________Area Code/Telephone #_______________________ Address, City, State, Zip ________________________________________________________ Signature of Defendant: _____________________________________ Staff review: ___________________________________ Date: ______________________ Documents Support Request Documents do not Support Request FOR COURT USE ONLY 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 ___________ Date ____________________________________ Judicial Officer Form Approved for Mandatory Use CL-01 (Adopted 01/01/10, Revised 01/01/12, 01/01/13, 01/01/16) REQUEST TO VACATE CIVIL ASSESSMENT (PC1214.1(b)) www.imperial.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com