Traffic Amnesty Participation Form

Statewide Traffic Amnesty Program October 1, 2015 to March 31, 2017 Participation Form Case #: ___________________ Date: __________________ Driver's License Number: ______________ State: ____ Name: ________________________________________ E-mail: _______________________________________ Current Address: __________________________________________________________________________ Contact Number(s): Home: _____________________ Mobile: _________________ Work: _________________ I am seeking (select one or both) Reduction in eligible unpaid bail/fines/fees Driver's license reinstatement 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 made no payments to the court, county, or collecting entity for the eligible violation after September 30, 2015. 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. 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 at time of filing in order to participate. If I stop making payments on my amnesty case, the remaining balance may 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. I understand that DMV will charge a driver's license reinstatement fee of $55, as applicable. Complete either Section A or B as directed: A. I certify that I receive the following public assistance (check all that apply): (CAPI) Supplemental Security Income/SSI County relief, general relief, or general In-Home Supportive Services (IHSS) assistance Tribal Temporary Assistance for Needy Families State Supplementary Payment/SSP (TANF) CalWORKs CalFresh (Supplemental Nutrition Assistance Medi-Cal Program) Cash Assistance Program for Immigrants B. I certify the following: My total gross monthly household income is $________ and a total of ____ dependents live in the household. 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. Signature__________________________________ Date ____________________ Rev. 8/25/2015 American LegalNet, Inc. www.FormsWorkFlow.com