Local Court Form (Rev. 07/01 / 20 18 ) SB - 16351 (Optional Use) REQUEST FOR CONSIDERATION OF ABILITY TO PAY CONFIDENTIAL Page 1 of 2 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO CONFIDENTIAL STREET ADDRESS: CITY AND ZIP CODE: DISTRICT NAME: FOR COURT USE ONLY PLAINTIFF: People of the State of California vs. REQUEST FOR CONSIDERATION OF ABILITY TO PAY F ill out this form to request a lower fine, a payment plan, more time to pay, and/or community service. This form is used for infractions o nly , and can not be used for misdemeanors , parking tickets, or felonies . Citation or Case No.: Charges : 1.247 2.247 3.247 4.247 5.247 REQUEST WHAT ARE YOU ASKING THE COURT TO DO ? Check all that you are willing and able to do: (I understand that, by law, some fines/fees cannot be lowered.) Lower the amount I owe on the fine. Gi ve me more time to pay the fine or allow me to make monthly payments. Lower my current monthly payments to $ per month. Allow me to serve community se rvice instead of paying a fine. Check this box if this is not your first request to lower your fine or serve community service for this case.* * If you check this box, you must attach a statement telling the Court what has changed since your last request. PERSONAL INFORMATION: Your Name: Mailing Address: Date of Birth: City, State, Zip Code: Telephone Number: WHAT IS THE STATUS OF THIS CASE? Please check only one. OPTION 1 : I have NOT been to Court or signed an agreement to pay fines/fees on this citation, OR OPTION 2 : I HAVE been to Court on this ticket, but no pleas were ent ered and no fines/fees were set, OR OPTION 3 : The case has been heard by the Court and fines/fees imposed. I am requesting a modification to the current order. I F YOU CHOOSE OPTION 1 OR 2 , YOU MUST READ AND INITIAL THE FOLLOWING: I want to plead guilty to all charges and have the court rule on my fines/fees. I have read the Advisal of Rights on the reverse of this form, and I understand my in i tials and signature on this form are an admission of GUILT (initial here) American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Citation or Case Number: Local Court Form (Rev. 07/01 /2018 ) SB - 16351 (Optional Use) ORDER ON REQUEST FOR CONSIDERATION OF ABILITY TO PAY CONFIDENTIAL Page 2 of 2 ADVISEMENT OF RIGHTS By choosing to pay and forfeit bail and not go into court, you will be giving up these rights: To appear in court without deposit of bail for formal arraignment, plea, and sentencing; To request and have a court trial without deposit of bail, unless the court orders bail, 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 or present witnesses and physical evidence using the power of the court at no cost to you and to 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 declare under penalty of perjury, under the laws of the State of California, that all information on this form, including any attachments, is true and correct. Signature Date Print your name here INCOME INFORMATION: Your Monthly Income: $ Source (Job, TANF, SSI, Disability, etc.) Other Household Income: $ Source (Job, TANF, SSI, Disability, etc.) Number of Children in Household: Total number in Household: I currently receive the following (check all that apply): AFDC/TANF CalFresh CalWorks or Tribal TANF CAPI County Relief/General Assistance IHSS SSI or SSP Your Monthly Expenses (list amounts for all that apply): Car/Gas: Childcare: Child Support: Food: Health Insurance: Rent/Mortgage: Student Loans: Utilities : Please provide any additional information or documentation : American LegalNet, Inc. www.FormsWorkFlow.com