SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA Santa Barbara Division 118 East Figueroa St. Santa Barbara, CA 93101 (805) 568-3959 PLAINTIFF: DEFENDANT: FOR COURT USE ONLY Santa Maria Division 312 East Cook St. Bldg. E Santa Maria, CA 93454 (805) 346-7550 Lompoc Division 115 Civic Center Plaza Lompoc, CA 93436 (805) 737-7789 People of the State of California FINANCIAL QUALIFICATION FOR WAIVER TO POST BAIL TRAFFIC - CONFIDENTIAL CITATION NUMBER: If you are receiving public benefits, are a low-income person, or do not have enough income to pay for household's basic needs and your bail, you may use this form to ask the court to waive the posting of your bail. 1. Why are you asking the court to allow you to waive the posting of your bail? I receive (check all that apply): Medi-Cal Food Stamps IHSS (In-Home Supportive Services CalWORKS SSI/SSP General Assistance If you checked any of the boxes above, stop here. Please sign and date the bottom of this form. If not, proceed to #2 2. Are you a dependant on anyone else's tax return (e.g., your parents)? 3. If the answer to #2 is yes, does that person refuse to pay for your infraction? 4. Your Household's income Source a. Gross monthly income (before deductions) $ $ $ $ $ $ Amount Yes Yes No No b. List the source and amount of any other income you receive each month, including: spousal/child support, retirement, social security, disability, unemployment, veterans payments, dividends, interest, trust income, annuities, or other income. TOTAL MONTHLY INCOME: 5. Household Members Name a) b) c) d) Age Relationship You are signing your request under penalty of perjury. Please answer truthfully and accurately. The court may ask you for information or evidence. You may be ordered to go to court to answer questions about your ability to pay court obligations. I declare under penalty of perjury that the information I have provided on this form is true and correct. Date: SIGNATURE SC-8021 [New January 1, 2016] FINANCIAL QUALIFICATION FOR WAIVER TO POST BAIL - CONFIDENTIAL American LegalNet, Inc. www.FormsWorkFlow.com