SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF: FOR COURT USE ONLY PEOPLE OF THE STATE OF CALIFORNIA DEFENDANT: CIVIL ASSESSMENT PETITION AND ORDER Defendant's Request and Declaration to Vacate Civil Assessment CASE NUMBER: IMPORTANT: Written proof of any of the following must be attached and cover the time period in question. HOSPITALIZED INCARCERATED OVERSEAS MILITARY DUTY OTHER The following is an explanation of my failure to pay. (Please print in English only.) 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. Executed at (City and State) on (Date) RESERVED FOR CLERK'S FILE STAMP Address Telephone Number: Signature: ORDER RE CIVIL ASSESSMENT (COURT USE ONLY) The Court having read and considered the Petition regarding vacating the Civil Assessment pursuant to PC 1214.1(B), hereby makes the following order: Petition to vacate is: Signature (Judicial Officer) Denied Granted Date If your petition is granted, the Department of Revenue will be notified for refund of the Civil Assessment fee. You may contact them at: MAIL ADDRESS: P.O. Box 1897 San José, CA 95109-1897 OFFICE ADDRESS: 1555 Berger Drive, Bldg. #2 San José, CA Telephone: (408) 282-3200 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com CR-6058 REV 8/12 CIVIL ASSESSMENT PETITION AND ORDER (CRIMINAL)