DEFENDANT: CASE NUMBER: GOOD CAUSE DECLARATION ­ REQUEST TO ADDRESS CIVIL ASSESSMENT INSTRUCTIONS: If you selected option 2 or option 3 on the Request to Address Civil Assessment, complete the information below and attach documentation supporting your request. I had a good reason for my failure to pay the required fine by the due date or for my failure to appear in court on or before my appearance date. The following is an explanation of the circumstances that caused me to fail to appear or pay: I have attached the supporting document(s) from to . I declare under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge. (SIGNATURE OF DEFENDANT) (DATE) Approved for Optional Use Riverside Superior Court RI-TR011 [Rev. 6/20/13] GOOD CAUSE DECLARATION riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com