American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF CALIFORNIA COUNTY OF MONO STAN ELLER HECTOR GONZALEZ, JR. Presiding Judge Court Executive Officer MARK MAGIT Assistant Presiding Judge 100 Thompsons Way Mailing Address : P.O. Box 1037 Mammoth Lakes , CA 9 3546 (760) 924 - 5444 Request to Vacate Civil Assessment (PC 1214.1) Petition and Order Form IMPORTANT: Provide a written explanation of any of the following that shows you were unable to appear or contact the court. Attach supporting documentation with your petition. Your petition may be denied if written proof is not receive HOSPITALIZED MILITARY DUTY RESIDENTIAL TREATMENT INCARCERATED DEATH EXTENUATING CIRCUMATANC E The following is an explanation of my failure to appear and/or pay: (Please print and include attachments) I declare under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge. SignatureDate Executed at O n City and State Date Mailing Address ORDER RE: CIVIL ASSESSMENT (COURT USE ONLY) Assessed Amount $ The Court having re ad and considered the Petition regarding vacating the Civil Assessment p ursuant to PC 1214.1, hereby makes the following order: GRANTED DENIED GRANTED IN PART: Civil Assessment Reduced to $ SignatureDate Judicial Officer American LegalNet, Inc. www.FormsWorkFlow.com