SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF NEVADA 201 Church Street, Suite 7, Nevada City, CA 95959 (530) 265-1311 10075 Levon Avenue, Suite 107, Truckee, CA 96161 (530) 582-7835 FOR COURT USE ONLY DEFENDANT: REQUEST FOR INSTALLMENT PAYMENTS & BAIL FORFEITURE 226 NON-TRAFFIC CASE NUMBER: PLEASE SIGN, DATE AND MAIL ORIGINAL DOCUMENT TO COURT Advisement of Rights By choosing to pay and forfeit bail in installments and not go into court, you will be giving up these rights: To appear in court for formal arraignment, plea and sentencing; To have a court trial and challenge the charges; To have a speedy court trial and have the charges dismissed if a speedy trial is requested but not provided; To be represented by an attorney at your expense; To subpoena and present witnesses and physical evidence using the power of the court at no cost to you and testify on your own behalf; To confront and cross-examine all witnesses under oath testifying against you; and To remain silent and not testify. I have read and give up those rights listed on the advisement above. I wish to forfeit the bail amount by paying in monthly installments which is the equivalent of a plea of guilty and a conviction. I promise to pay the fine of $ (including an installment payment fee of $75.00 - $100.00). I agree to make payments on this case in the amount of $ per month (minimum of 10% of total). Payments are due on or before the day of each month, starting . Thereafter, I promise to pay the monthly payment on or before the due date until the remaining balance is paid in full. Failure to pay the fine as indicated above may result in the following: Addition, to the amount you owe, of a Civil Assessment in the amount of $300.00 pursuant to Penal Code 247 1214.1. Referral of your case to the Franchise Tax Board for collection. Referral of your case to a contracted collection agency. There is no grace period for late payment. Signature: Date: Request for Installment Payments & Bail Forfeiture 226 Non-traffic LOCAL CL2 (Effective 8/15/14) 226 MANDATORY FORM American LegalNet, Inc. www.FormsWorkFlow.com