FL/E-LP-657 NAME, ADDRESS, AND NAME OF CORRECTIONAL INSTITUTION For Court Use Only X-REF NO. SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO STREET ADDRESS: 3341 Power Inn Road MAILING ADDRESS: Same CITY AND ZIP CODE: Sacramento, CA 95826 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: INMATE REQUEST FOR PAYMENT PLAN CASE NUMBER: Notwithstanding any other provision, a person who is sentenced to the state prison or confined to a county jail shall pay the full amount of the trial court filing fees and costs. If you do not have enough income to pay your court fees, you may use this form to ask the court to set a payment plan on all or part of your court fees. The court may order you to answer questions about your finances. If the court grants a payment plan for the fee, you may be required to pay in a lump sum later if: 1. You cannot give the court proof of your inmate status, or Your financial situation improves during this case. I declare that I am incarcerated and my current address is: __________________________________________________________________________________________ __________________________________________________________________________________________ I have attached a Statement of Account certified by the appropriate official of the Department of Corrections and Rehabilitation or a county jail. 2. You must complete either section 3 a or 3 b below. 3. a) [ ] I have included a partial payment towards the filing fee of 20% of: [ ] The average monthly deposits to my account, or [ ] The average monthly balance in my account for six-months immediately preceding this request or b) [ ] The attached Statement of Account shows that there are no funds in my account. 4. What court fees or costs are you asking for a payment plan? [ ] Filing papers in Superior Court [ ] Giving notice and certificates [ ] Making copies and certifying copies [ ] Sending papers to another court department [ ] Sheriff's fee to give notice [ ] Court-appointed interpreter [ ] Reporter's daily fee [ ] Court fees for phone hearings [ ] Other (Specify): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ FL/E-LP-657 Adopted 6/19/14 Mandatory INMATE REQUEST FOR PAYMENT PLAN American LegalNet, Inc. www.FormsWorkFlow.com Gov Code 68635 Page 1 of 2 www.saccourt.ca.gov FL/E-LP-657 I declare under penalty of perjury under the laws of the State of California that the information I have provided on this form and all attachments is true and correct. Date: ___________________________ ________________________________ Print your name here _____________________________________________ Sign here FL/E-LP-657 Adopted 6/19/14 Mandatory INMATE REQUEST FOR PAYMENT PLAN American LegalNet, Inc. www.FormsWorkFlow.com Gov Code 68635 Page 2 of 2 www.saccourt.ca.gov