AMNESTY PROGRAM Statewide Traffic Tickets/Infractions Superior Court of California, County of Santa Clara October 1, 2015 to March 31, 2017 Date: Driver's License Number: Name: E-mail: Current Address: Social Security Number: Citation/Court Case Number: Date of Birth: Contact Number(s): Home Mobile: Work: 1. I am seeking (select one or both): Reduction in eligible unpaid bail/fines/fees Driver's license reinstatement 2. In order to be eligible for a reduction in my unpaid bail/fines/fees, I declare all of the following are true: · I do not owe restitution to a victim within the county where the violation occurred. · I do not have any outstanding misdemeanor or felony warrants in the county where the violation occurred. · I made no payments to the court, county, or collecting agency for the eligible violation after September 30, 2015. 3. In order to be eligible for the restoration of my driver's license only, I declare one or both of the following is true: a. I have appeared and satisfied all my court-ordered obligations in this county. b. I am making payments to a comprehensive collections program on eligible violations and I am current on my installment payment plan. 4. By signing below, I confirm that I understand each of the following: · I must pay the reduced balance owed in full at this time or comply with terms of the approved payment plan. · I will pay an amnesty program fee of $50 in order to participate. · If I stop making payments on my amnesty case, the remaining balance may be referred to the Franchise Tax Board or a third party for collection. · If my case is determined not to be eligible at a later time, I may have to pay the adjusted or full amount. (See reverse for details.) Complete Either Section A or B A. I declare under penalty of perjury under the laws of the State of California that the following is true and correct to the best of my knowledge and belief: I receive the following public assistance (check all that apply): Supplemental Security Income/SSI County relief, general relief, or general assistance State Supplementary Payment/SSP CalWORKs Medi-Cal Cash Assistance Program for Immigrants (CAPI) In-Home Supportive Services (IHSS) Tribal Temporary Assistance for Needy Families (TANF) CalFresh (Supplemental Nutrition Assistance Program) B. I declare under penalty of perjury under the laws of the State of California that the following is true and correct to the best of my knowledge and belief: My total gross monthly household income is _______________________________________________________ And a total of _____________________ dependents live in the household. I understand that if I provide incorrect or inaccurate information, the debt reduction amount may change and I will be responsible for payment of the adjusted or full amount. Signature: TR-7003 REV 2/4/16 (V.C. § 42008.8) Date: Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com AMNESTY PROGRAM Statewide Traffic Tickets/Infractions Superior Court of California, County of Santa Clara October 1, 2015 to March 31, 2017 Are you eligible for the 50% amnesty reduction? After you submit this amnesty request, if the court, county, or collecting agency discovers that you are not eligible for amnesty because you have 1 or more outstanding warrants or owe victim restitution in this county, you will receive written notice within 10 business days that your request is being suspended. You will then have 20 business days from the date on the notice to bring to the court, county, or collecting agency written proof that the outstanding warrant(s) and/or victim restitution issues have been fixed. If you do not respond to the notice, then on the 21st business day after the date of the notice, or earlier if your proof does not show that you are eligible for amnesty, your amnesty request will be retroactively cancelled and your previously reduced court-ordered amounts will be restored, and any amounts you paid will be credited toward your revised outstanding debt. You will receive the notice(s) described above at the address you provided on page one of this request. Are you eligible for the 80% amnesty reduction? After you submit this amnesty request, if the court, county, or collecting agency discovers that you are not eligible for the 80 percent reduction in bail, fines, and/or fees because you do not receive public assistance as listed or because your household income is too high, you will receive written notice within 10 business days that your amnesty discount will be revised. You will then have 20 business days from the date on the notice to bring to the court, county, or collecting agency written proof that you do receive the specified public assistance or that your income is at or below 125 percent of the federal poverty rate for your household. If your written proof shows that you are eligible, your court-ordered amount will be revised to 20 percent of the amount owed. If you do not respond to the notice, then on the 21st business day from the date on the notice, or earlier if your proof does not show that you are eligible for the 80 percent discount, the agency will cancel the discount, and the full amount will be imposed, and any amounts you paid will be credited toward your revised outstanding debt. You will receive the notice(s) described above at the address you provided on page one of this request. If you are eligible for either amnesty program: A one-time $50.00 administrative fee is due with your first payment. And, if you choose installment payments, the minimum payment amount is $25.00. Payment in full or the first installment payment must be received by the Court no later than March 31, 2017. Your driver's license will not be reinstated for 20 days if you pay by check. FOR OFFICIAL USE ONLY Court case number: Total adjusted balance: The Superior Court of California, County of Santa Clara has verified case eligibility for the amnesty program and has determined the following: Eligible for: 50% reduction 80% reduction Not eligible for the following reasons (check all that apply): Outstanding warrant Due date after Jan 1, 2013 Restitution owed Payment received after Sep 30, 2015 Ineligible violations Not current on payments in a comprehensive debt collection program (driver's license reinstatement only) Certified by: ____________________ TR-7003 REV 2/4/16 (V.C. § 42008.8) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com