Amnesty Program Participation Form (Confidential) {MO-052}

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO CENTRAL DIVISION, KEARNY MESA, 8950 CLAIREMONT MESA BLVD., SAN DIEGO, CA 92123 CENTRAL DIVISION, JUVENILE COURT, 2851 MEADOW LARK DR., SAN DIEGO, CA 92123 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020 NORTH COUNTY DIVISION, 325 S. MELROSE DR., SUITE 350, VISTA, CA 92081 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910 AMNESTY PROGRAM PARTICIPATION FORM (CONFIDENTIAL) Name: Case Number: ___________________________ Address: ________________________________________________________________________________________ City: State: Zip Code: ____________________________ Home/Cell Tel. No.: ( ) Work Tel. No.: ( ) Driver License Number: State: ___________ Social Security Number: I, the defendant in this case, am seeking: Reduction in eligible unpaid bail/fines/fees and declare the following: I do not owe victim restitution on any case within San Diego County. I do not have any outstanding misdemeanor or felony warrants within San Diego County. I am not currently making payments on this case and have not made any payments after September 30, 2015. Driver License Hold Release Notification to DMV and declare the following: I am in good standing with the collections program and current on my installment payments as of today. I understand and accept the following conditions: If applying for a reduction, I must pay the reduced balance owed in full forthwith or comply with terms of the courtapproved payment plan. If I stop making payments on my amnesty case, the remaining balance will be referred to the Franchise Tax Board or a private vendor for further collection efforts. I am responsible for a non-refundable Amnesty Program fee of $50 to be paid forthwith. If you receive public benefits, or are a low-income person, you may complete the applicable portion of the form below, under penalty of perjury, to see if you qualify for an additional reduction of the eligible fine or bail. I receive the following public assistance (mark all that apply): Supplemental Security Income (SSI) State Supplementary Payment (SSP) In-Home Supportive Services (IHSS) CalFresh (Supplemental Nutrition Assistance Program) Tribal Temporary Assistance for Needy Families (TANF) County Relief, General Relief, or General Assistance CalWORKs Cash Assistance Program for Immigrants (CAPI) Medi-Cal I do not receive public assistance and certify that my total monthly household income is $___________ and ______ people (including all dependents and myself) live in the household. I further understand the following: If amnesty or the 80% reduction of bail/fine/fees is approved based on the information I provided in this form, and the court subsequently discovers that I am not eligible because either I have one or more outstanding warrants or owe victim restitution in San Diego County, or I am not receiving public assistance as listed or because my household income does not fall below 125 percent of the federal poverty rate, I will be notified within five court days that my participation is being suspended or that my amnesty reduction will be revised to 50 percent, as applicable. I will then have 20 court days to bring written proof to the court that I am in fact eligible. On the 21st day, or if the information I provide does not demonstrate that I am eligible for amnesty or for the 80 percent discount as applicable, the court will retroactively either cancel the Amnesty Program or revise the discount to 50 percent of the amount owed for court-ordered debt. Any paid amounts will be credited toward my revised outstanding debt. I will be sent notice of this action at the address I provided on this form. _______ Initials By signing below, I declare under penalty of perjury under the laws of the State of California that I am the defendant in this case, that I have read, understand, and accept the terms and conditions stated above, and 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. Date: For Office Use Only: Def. Eligible ( 50% 80% DL Release Only) Ineligible: Processed by: Dist.: ________Def. ________Accounting SDSC MO-052 (Rev. 10/15) Mandatory Form ______________________________________ Signature AMNESTY PROGRAM PARTICIPATION FORM (CONFIDENTIAL) Veh. Code § 42008.8 American LegalNet, Inc. www.FormsWorkFlow.com