Rev 10/18/18 Qualifications for Reduced Monthly Payment Amounts OR Program Verification SSI/SSP Medi - Cal Card or Notice of Planned Action or SSI Computer - Generated Printout or Bank Statement Showing SSI CalWORKs/TANF(formerly known as AFDC) Medi - Cal Card or Notice of Action or Income an d Eligibility Verification Form or Monthly Reporting Form or Electronic Food Stamp Program Notice of Action or Food Stamp ID card or General Relief/General Assistance Notice of Action or Copy of Check Stub or County Voucher NUMBER IN FAMILY FAMILY INCOME 1 $ 1, 264.59 2 $ 1, 714.59 3 $ 2 , 164.59 4 $ 2, 614.59 5 $ 3,064.59 6 $3,514.59 Each Additional $ 4 50.00 American LegalNet, Inc. www.FormsWorkFlow.com I am requesting a reduced monthly payment: 3. I am receiving financial assistance under one or more of the following programs: a. SSI and SSP: Supplemental Security Income and State Supplemental Payments Programs b. CalWORKS: California Work Opportunity and Responsibility to Kids Act, implementing TANF, Temporary Assistance for Needy Families(formerly AFDC) c. Food Stamps: The Food Stamps Program d. County Relief, General Relief(G.R.), or General Assistance(G.A.) [If you checked box 3 above, skip items 4 and 5 , and sign at the bottom of this form.] 4. My monthly Income a. Salary or wages(gross, before taxes) $ b. Overtime(gross, before taxes) $ c. Commissions or bonuses $ Total Income before taxes $ d. My payroll deductions are: $ My Monthly Take-home pay $ 5. Number of person living in my home Below list all the persons living in your home, including spouse, who depend in whole or part on you for support, or on whom you depend in whole or in part for support: Nam e Age How is the person related to you? Gross monthly income Pays some of the household expenses? Yes No Yes No Yes No Yes No Yes No I declare under penalty of perjury under the laws of the State of California that the information on this form is true and correct. Date: (print name) (signature) Superior Court of California, County of Yolo 1000 Main Street Woodland, Ca. 95695 530 - 406 - 6703 The People Vs. , Defendant For Court Use Only Case No: Application for Reduced Monthly Payment; Income Declaration American LegalNet, Inc. www.FormsWorkFlow.com