Superior Court of California, County of Alameda
Statewide Traffic Tickets/Infractions Amnesty Program
Sample Participation Form
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name: |
|
|
|
DL Number: |
|
|
|
State: |
|
|
|
Current Address: |
|
|
|
City, State, Zip: |
|
|
|
|
|
|
E-mail: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Contact Number(s): Home: |
|
Mobile: |
|
Work: |
|
|
|
1. I am seeking (select one): |
|
|
|
|
|
|
|
|
|
|
|
|
A. Reduction in eligible unpaid bail/fines/fees and Driver’s Lice se rei state |
e t |
|
In order to be eligible, I declare that all of the following are true (check the box for each true statement):
I do not owe restitution to a victim in Alameda County.
I do not have any outstanding misdemeanor or felony warrants in Alameda County.
I made no payments for the eligible violation(s) after Sept. 30, 2015.
OR
B. Driver’s lice se rei state e t o ly
In order to be eligible, I declare that the following is true (check the box if true):
I am current in my payments to the court, county, or a collecting entity for eligible tickets.
2.Financial Information: Please complete either A. or B.
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 assistance |
In-Home Supportive Services (IHSS) |
State Supplementary Payment/SSP |
Tribal Temporary Assistance for Needy Families |
CalWORKs |
(TANF) |
Medi-Cal |
CalFresh (Reduced/Free Lunch Program, Food |
|
Stamps) |
B.I do not receive any form of public assistance listed above, and I certify that my total gross monthly household income is $________ and a total of ____ people (including myself and all dependents) live in the household.
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 am responsible for an amnesty program fee of $50 in order to participate.
∙If I stop making payments on my amnesty case, the remaining balance will 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.)
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.
Superior Court of California, County of Alameda
Statewide Traffic Tickets/Infractions Amnesty Program
Sample Participation Form
PLEASE NOTE THE FOLLOWING:
Your participation may be cancelled if you provide incorrect information regarding victim restitution or warrants.
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 that your form is being suspended. You will then have 20 business days to bring written proof to the court 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.
Your 80% reduction may be changed to a 50% reduction if you are found not to qualify for the larger 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 at or above 125 percent of the federal poverty rate, you shall be notified 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 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.
