Amnesty Program Participation Application

THIS FORM TO REMAIN CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SUTTER STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 1175 Civic Center Blvd. 1175 Civic Center Blvd. Yuba City, CA 95993 CASE NUMBER: AMNESTY PROGRAM PARTICIPATION APPLICATION Date: Name: Current Address (include city, state, & zip code): Current Telephone #: 1. I am seeking (check all that apply): E-mail Address: Driver's License #: State: Social Security #: Reduction in eligible unpaid bail/fines/fees Driver's license reinstatement. 2. 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 have made no payments to the court, county, or collecting agency for the eligible violation after June, 24, 2015. 3. 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 a person in good standing and making payments to a comprehensive collections program on eligible violations. 4. I certify my total gross monthly household income is: $ and a total of: dependents live in the household. 5. COMPLETE THIS SECTION ONLY IF YOU RECEIVE PUBLIC ASSISTANCE A. I certify that I receive the following (check all that apply): Supplemental Security Income (SSI) County or general relief, or general assistance State Supplementary Payment (SSP) CalWORKS Medi-Cal Cash Assistance Program for Immigrants (CAPI) In-Home Supportive Services (IHSS) Tribal Temporary Assistance for Needy Families (TANF) CalFresh (Supplemental Nutrition Assistance Program) 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 $50.00 in order to participate. If I stop making payments on my amnesty case, the remaining balance may be referred to the Franchise Tax Board (FTB) 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. Date: (SIGNATURE OF APPLICANT) Local Form Approved for Optional Use Sutter County Superior Court Effective: October 1, 2015 Revised: January 19, 2016 AMNESTY PROGRAM PARTICIPATION APPLICATION Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com PLEASE NOTE THE FOLLOWING: You will be notified by E-mail at the address provided on the front of this sheet as to your eligibility for the amnesty program within five (5) business days from submission of this form. If you have not heard back from the court within 10 business days please contact us to find out the status of your application. Are you eligible for the 50% amnesty reduction? If, after this form is submitted, the court discovers you are not eligible for amnesty because you have one (1) or more outstanding warrants or owe victim restitution in this county, your application will be suspended. You will then have 20 business days to bring written st proof to the court that the outstanding warrant(s) and/or victim restitution issues have been resolved. On the 21 business day, or earlier if the information you provide does not demonstrate eligibility for the amnesty program, the court will retroactively cancel the amnesty program, restore previously reduced court-ordered amounts, and credit any paid amounts toward your revised outstanding debt. The court will notify you of this action. Are you eligible for the 80% amnesty reduction? If, after this form is submitted, the court discovers you are not eligible for the 80% 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% of the federal poverty rate, you will be notified that your amnesty discount will be revised. You will then have 20 business days to bring written proof to the court that you do receive the specified public assistance or that your income is at or below 125% of the federal poverty rate for your household. On the st 21 business day, or earlier if the information you provide does not demonstrate that you are eligible for the 80% discount, the court will determine whether to revise the discount, if you are eligible, to 50% 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 will notify you of this action. FOR COURT USE ONLY Original Due Date: Citation Number: Victim Restitution owed in Sutter County: No Yes, Amount: $ No Yes Total outstanding balance: Amnesty payment due: Verified by: Outstanding misdemeanor or felony warrants in Sutter County: Last payment was received on: NOT ELIGIBLE FOR AMNESTY VERIFIED ELIGIBLE FOR: 50% 80% Reduction Driver's License Reinstatement Date: COURT CLERK: Local Form Approved for Optional Use Sutter County Superior Court Effective: October 1, 2015 Revised: January 19, 2016 AMNESTY PROGRAM PARTICIPATION APPLICATION Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com