CI VIL ASSESSMENT FOR FAILURE TO APPEAR OR FAILURE TO PAY Instruction and Information Sheet INSTRUCTIONS : all NOTE Information about Civil Assessments : What is a Civil Assessment? How is the Civil Assessment imposed? Is there a grace period? What are the consequences of a Civil A ssessment for a failure to appear ? NOTE : What if I have moved? Can there be m ore than one Civil Assessment added to my case? What is Good Cause? Steps to Resolving Your Civil Assessment Step 1: Step 2: enBanning enBlythe Corona enHemet enIndio es-MXMurrieta enRiverside enMoreno Valley, Page 1 of 1 Approved for Optional Use Riverside Superior Court RI - OTS38 - INFO [ Rev. 07/01/19 ] R EQUEST TO ADDRESS CIVIL ASSESSMENT FOR FAILURE TO APPEAR OR FAILURE TO PAY - INSTRUCTION AND INFORMATION SHEET PC 2471214.1(a) riverside.cour ts.ca.gov/localfrms /localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE (DEFENDANT NAME) (ADDRESS ) Check here if your address has changed. (CITY) (STATE) (ZIP) (TELEPHONE) People of the State of California, REQUEST TO ADDRESS CIVIL ASSESSMENT FOR FAILURE TO APPEAR OR FAILURE TO PAY (PC 247 1214.1 (a) ) Plaintiff: DECLARATION IN SUPPORT OF REQUEST v . Defendant: CASE NUMBER: In accordance with P enal Code section 1214.1 (a) , t he Cou rt imposed a Civil Assessment on your case in lieu of issuing a warrant . NOTE : Only one request to address this civil assessment may be filed for each citation. Please select one of the following options (1, 2 or 3) : OPTION 1: E stablish payment arrangements. (N o court appearance required) : You may set up a m onthl y payment plan. For more information you may visit our website at www.riverside.courts.ca.gov and s elect the payment plan option. You may also establish payment arrangements based on your personal financial evaluation . Please contact the Enhanced Collections Division (ECD) at 1 - 877 - 955 - 3463 . OPTION 2: Submit a statement and attach supporting document s . (Court appearance may be required) : You must show good cause (explain in writing the circumstance beyond your control) as to why you failed to appear or failed to pay; and you must attach documentation to support the explanation which include s writ ten proof of the following: Good Cause Statement: I failed to appear in court or I had good reason for not paying my fine when due for the following reason(s): A. Medical Incapacitation/Hospitalization I have attached proof of incapacitation/hospitalization from to . B. Incarceration . I have attached proof of incarce ration from to . C. Military Orders . I have attached proof of military orders for the dates of . IMPORTANT: Attach copies only of written proof , originals will not be returned to you. OPTION 3 : . (Court appearance may be required) : You MUST submit a good cause statement and attach supporting documents. Good Cause Statement: I failed to appear in court or I had good reason for not paying my fine (other than those reasons listed in option 2) when due. I have attached a good cause statement and the supporting document (s) from to . I understand that I may be ordered to appear in court to explain these circumstances . NOTE: The Court will notify you regarding all required court appearances. I declare under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge and that written proof is attached to this form as required . Page 1 of 1 R EQUEST TO ADDRESS CIVIL ASSESSMENT FOR FAILURE TO APPEAR OR FAIL URE TO PAY - PC 2471214.1 (a ) American LegalNet, Inc. www.FormsWorkFlow.com