COL-003-2016-M Mandatory Form Revised December 2017 SUPERIOR COURT OF CALIFORNIA, COUNTY OF TULARE Collections Division 221 S Mooney Blvd, Room G - 28 Visalia, CA 93291 Phone 559 - 730 - 5000 For Court Use Only Plantiff: People of the State of California vs. Defendant: COLLECTION INSTALLMENT APPLICATION Case Number Additional Case Numbers: Last Name: First Name: Address: City: State: Zip Code: Phone #:Date of Birth: Social Security #: Relative/Friends Name and Phone #: The total fine amount includes applicable penalty assessments as required by law, plus a $35 installment fee per case. PAYMENT TERMS: Balance Due: Minimum monthly payment will be $ Commencing on & due on the of each month until paid in full. I understand that: All payments must be made by the due date every month. If I do not make my payments my case or cases will be assigned to a private collection agency or the State Franchise Tax Board for further collection. The the amount owed is paid in full. Signature: Date: Payments may also be made by credit card via the internet at www.tularesuperiorcourt.ca.gov or by contacting the court directly at (559) 730-5000 option 1, option 3 between the hours of 8:00 a.m. to 4:00 p.m. weekdays. The returned Check Fee is 25.00. Superior Court of California, County of Tulare Attn: Collections Department 221 S. Mooney Blvd., RM G28 Visalia, CA 93291 FINANCIAL HARDSHIP AND PAYMENT PLANS At any time before your final payment, if you experience a change in financial circumstances, you may ask the court to consider your ability to pay. When considering your ability to pay, the court may modify your installment plan, allow you to complete community service (if available) instead of paying the total amount due, or suspend all or part of the fine. The court is not required to offer you any of the above options and the court may deny your request. You may schedule an appearance in court for an Arraignment without the deposit of bail. American LegalNet, Inc. www.FormsWorkFlow.com