Amnesty Eligibility Declaration Form - 2015 - Superior Court Of California, County Of Santa Barbara
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1
2FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA
Santa Barbara Division
Santa Maria Division
Lompoc Division
118 East Figueroa St.
312 East Cook St. Bldg. E
115 Civic Center Plaza
Santa Barbara, CA 93101
Santa Maria, CA 93454
Lompoc, CA 93436
(805) 568-3959
(805) 346-7550
(805) 737-7789
People of the State of California
PLAINTIFF:
DEFENDANT:
DOB:
CASE NUMBER:
AMNESTY ELIGIBILITY DECLARATION – 2015
Current Address:
SSN#:
Phone Numbers:
Home:
Mobile:
Work:
Driver’s License Number:
State:
E-mail:
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 Sept. 30, 2015.
In order to be eligible for the restoration of my driver’s license only, I declare one or both the following is true:
I have appeared and satisfied all my court-ordered obligations in this county.
I am currently making payments to the court, county, or collecting entity for tickets due after January 1, 2013.
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 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. (See page 2 for details.)
Complete Either Section A or B as Directed:
A.
I certify that I receive the following public assistance.
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 Temp Assistance for Needy Families (TANF)
CalWORKs
CalFresh (Suppl Nutrition Assistance Program)
Medi-Cal
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: _____________________
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