FINANCIAL DECLARATION ­ CRIMINAL FAILURE TO APPEAR Comprehensive Collections Unit Instructions, Petition and Declaration to Vacate Civil Assessment [PC1214.1] THE PEOPLE OF THE STATE OF CALIFORNIA, Plaintiff, Vs. _______________________________________ Case Number/ Docket Number: Defendant, Case Balance: _____________ Superior Court of California County of San Luis Obispo Date: __________ ____________ If you do not complete the Petition and PROVIDE DOCUMENTATION OR THE REQUIRED FINANCIAL DECLARATION, the Court will not consider your Petition. ___ I request to appear in court and have posted the full bail due at this time, including civil assessments. ___ I request to appear in court without posting bail; the completed Financial Declaration form is attached. This form is not applicable if you appeared in court and failed to pay the fine amount ordered. YOU MUST ATTACH YOUR DOCUMENTATION IN SUPPORT OF THIS REQUEST Please state your reason(s) below for petitioning to appear in court: I declare under penalty of perjury under the Laws of the State of California that all of the information contained in this Petition, and the documents attached, are true and correct. Defendant's Signature Date *************************************************below for Court use only************************************************* Petition Approved / Denied by Court Officer Date Please return completed form to: Fiscal Department c/o 1050 Monterey Street, Room 220 San Luis Obispo, CA 93408 American LegalNet, Inc. www.FormsWorkFlow.com FINANCIAL DECLARATION ­ CRIMINAL FAILURE TO APPEAR Full Name:___________________________________________ Address:____________________________________________ Street City Zip Marital Status: Date of Birth:___________ Telephone:_____________ Single_____ Married_____ Divorced_____ Separated_____ Widowed_____ Children: Number________ Ages____________ Driver's License No._________________ Name of Spouse:_______________________ Social Security Number:____________________ EMPLOYMENT RECORD Employer: Address: City: Type of Job: Gross Salary: Take Home: ______________________________ ______________________________ ______________________________ ______________________________ $________________ (Week / Month) $________________ (Week / Month) SPOUSE EMPLOYMENT Employer:________________________________ Address:_________________________________ City: __________________________________ Type of Job: ______________________________ Gross Salary: Take Home: $______________(Week / Month) $______________ (Week / Month) OTHER INCOME Unemployment & Disability Social Security Welfare, AFDC Workers Compensation Child Support Payments Support from Parents All Other Income $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $______________ LIST YOUR MONTYLY EXPENSES Rent or House Payment Car Payments Medical Payments Loan Payments Clothing & Laundry Other Payments $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ WHAT DO YOU OWN? LIST VALUE Cash $____________________________ House: $____________________________ Cars & Other Vehicles: $_____________________ Life Insurance: $______________________ Bank Accounts:$___________________________ WHO DO YOU OWE? Monthly Payment Balance Owed Name ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ Name of Bank Branch I declare under penalty of perjury that the foregoing Financial Declaration is true and correct and if sworn as a witness, I could testify competently thereto. Executed at___________________, this _______day of____________, 20____. ______________________________________ Signature of Petitioner Please return completed form to: Fiscal Department c/o 1050 Monterey Street, Room 220 San Luis Obispo, CA 93408 American LegalNet, Inc. www.FormsWorkFlow.com