Traffic Tickets/Infractions Amnesty Program Participation Form ­ Stanislaus Superior Court October 1, 2015 to March 31, 2017 Recv'd: // - Driver's License Number: Name: Address: City: Phone Number(s): Cell: ___________ Home: Date of Birth: Case#: State: Zip Code: Work: All sections above must be completed. If your phone number or address changes, it is your responsibility to report it to the Court. I am seeking (select one or both) Reduction in eligible unpaid bail/fines/fees Driver's license reinstatement 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 entity for the eligible violation after September 30, 2015. In order to be eligible for the restoration of my driver's license only, I declare one or both of the following is true: I have appeared and satisfied all my court-ordered obligations in this county. I am currently making payments to the court, county, or a collecting entity for tickets due after January 1, 2013. By signing below, I affirm 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 may be responsible for 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 ineligible at a later time, I may be responsible for payment of the re-adjusted or full amount. (See reverse for details.) Complete either Section A or B as directed: A. I certify that I receive the following public assistance (check all that apply): Supplemental Security Income/SSI Cash Assistance Program for Immigrants (CAPI) County relief, general relief, or general In-Home Supportive Services (IHSS) assistance Tribal Temporary Assistance for Needy Families (TANF) State Supplementary Payment/SSP CalWORKs CalFresh (Supplemental Nutrition Assistance Program) Medi-Cal B. I certify the following: My total gross monthly household income is $________ and a total of ____ dependents (including myself) live in the household. I declare under penalty of perjury under the laws of the State of California that the foregoing statements are true and correct to the best of my knowledge and belief. 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 re-adjusted or full amount. I also understand that if I am found eligible for reduction and I have not previously appeared or submitted a plea, I will be entering a plea of "no contest" on this case when making payment under the amnesty program. Signature:___________________________________________ Date:____________________ Rev. 10/28/15 sa American LegalNet, Inc. www.FormsWorkFlow.com Traffic Tickets/Infractions Amnesty Program Participation Form ­ Stanislaus Superior Court October 1, 2015 to March 31, 2017 PLEASE NOTE THE FOLLOWING: Are you eligible for the 50% amnesty reduction? If, after this form is submitted, the court/county/collecting entity discovers you are not eligible for amnesty because you have 1 or more outstanding warrants or owe victim restitution in this county, you shall be notified within 5 business days that your form is being suspended. You will then have 20 business days to bring written proof to the court/county/collecting entity that the outstanding warrant(s) and/or victim restitution issues have been addressed. On the 21st business day, or earlier if the information you provide does not demonstrate you are eligible for amnesty, the court/county/collecting entity will retroactively cancel the amnesty program, restore previously reduced court-ordered amounts, and credit any paid amounts toward your revised outstanding debt. The court/county/collecting entity will send you notice of this action to the address indicated on this document. Are you eligible for the 80% amnesty reduction? If, after this form is submitted, the court/county/collecting entity discovers you are not eligible for the 80 percent reduction in bail/fines/fees because you are not receiving public assistance as listed or because your household income is not at or below 125 percent of the federal poverty rate, you shall be notified within 5 business days that your amnesty discount will be revised to 50 percent. You will then have 20 business days to bring written proof to the court/county/collecting entity that you do receive the specified public assistance or that your income is not at or below 125 percent of the federal poverty rate for your household. On the 21st business day, or earlier if the information you provide does not demonstrate that you are eligible for the 80 percent discount, the court/county/collecting entity will determine whether to revise the discount, if you are eligible, to 50 percent of the amount owed for court-ordered debt or impose the full amount as discussed above and credit any paid amounts toward your revised outstanding debt. The court/county/collecting entity will send you notice of this action to the address indicated on this document. Total outstanding balance: $ Status of Case: FOR COURT USE ONLY Amnesty payment due: $ ____ Court Case ____ Franchise Tax Board* ____ Municipal Services Bureau** __Revenue and Recovery Case ­ You must contact Revenue and Recovery @ (209) 525-4450, 1010 Tenth St. Suite 2500, Modesto CA __Has another Amnesty case with Superior Court. Must show receipt for amnesty fee to Revenue and Recovery. The Superior Court of California, County of Stanislaus has verified case eligibility for the amnesty program and has determined the following: Eligible for: ____50% reduction and driver's license release ____80% reduction and driver's license release ____Driver's License Reinstatement only (due date after 1/1/2013) Note: If you have been found ineligible, you may be eligible to reapply if you have corrected the issues for which you were found ineligible. If you are not in good standing on a case in collections, once you have made payments and we receive notice, you can reapply. Not eligible for (check all that apply): ____50% reduction ____80% reduction ____Driver's License R