Statewide Traffic Tickets/infractions Amnesty Program Application Form September 2015

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Statewide Traffic Tickets/Infractions Amnesty Program Application Form
Completed form must be submitted starting October 1, 2015 and on or before March 31, 2017 to Mono County Superior Court
PLEASE NOTE: Application process can take up to 3-4 weeks
Date: _____________ Driver’s License Number: _______________________ State Issued License: ____________
Name: _________________________________________________ E-mail: _______________________________
Current Address: ___________________________________________________________ Zip Code ___________
Contact Number(s): Home: ____________________ Mobile: ____________________
I am seeking (check 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 have a traffic or non-traffic infraction in Mono County Superior Court
(parking violations, DUI & “reckless” driving violations are not
that . . .
eligible)
o
my final court appearance date was on or before January 1, 2013 and I failed to appear
o
or my fine due date was on or before January 1, 2013; and I have an installment payment plan but I haven’t made a
payment since September 30, 2015 (if you made payment after September 30, 2015 you are ineligible for amnesty
reduction but you may be eligible to have your driver’s license reinstated, proceed to complete the form)
 I do not owe restitution to a victim for a violation occurred in Mono County.
 I do not have any outstanding misdemeanor or felony warrants in Mono County.
 I have made no payments to the Mono Superior Court or outside collection agency for the eligible violation after September 30,
2015.
In order to be eligible for the reinstating 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 Mono County.
I am a person in good standing and making payments to an installment payment Mono County Superior Court comprehensive
collections program on eligible violations
.
(parking violations, DUI & “reckless” driving violations are not eligible)
By signing below, I affirm that I understand each of the following:
I must pay the amnesty reduced bail/fine balance owed in full at this time or comply with terms of the approved payment plan.
I must pay an amnesty program fee of $50 in order to participate, which is in addition to my amnesty reduced bail/fine
amount.
If I stop making payments on my amnesty case, the remaining balance may be referred by Mono County Superior Court to the
Franchise Tax Board or an outside collection agency.
If my case is determined ineligible at a later time, I may be responsible for payment of the re-adjusted or full amount. (See
second page for details.)
Complete either Section A or B as directed:
A. If you receive public assistance only complete Section A, certify which of the following public assistance you receive
(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 (TANF)
CalWORKs
CalFresh (Supplemental Nutrition Assistance Program)
Medi-Cal
B. If you do not receive public assistance, only complete Section B, 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. This form must be signed by the person requesting
amnesty; unsigned forms will not be processed. This form must be submitted per the instructions below.
To submit this form (be sure to include both pages) you can come to the Mammoth Lakes Courthouse at 100 Thompsons Way, Mammoth Lakes, Ca. or
mail the form to the Mono County Superior Court, PO Box 1037, Mammoth Lakes, Ca., 93546. No faxed or emailed copies will be accepted.
This form must be received by the Court on or before March 31, 2017
Page 1 of 2
Rev. 9/25/2015

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