Statewide Traffic Tickets/infractions Amnesty Program Butte County - Participation Form
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3Butte County
Statewide Traffic Tickets/Infractions Amnesty Program
October 1, 2015 to March 31, 2017
Participation Form
The information requested below will be used for case research and case identification.
Date:
Driver’s License Number:
State:
D.O.B:
SSN:
Name (List all names used/AKA’s):
Current Address (where you receive mail)
Contact Number(s):
Please contact me via: Phone
Mail
I am seeking (select one or both)
Reduction in eligible unpaid bail/fines/fees
Driver’s license reinstatement
Case number(s) I want considered for amnesty reduction (list all cases you want reviewed):
Case number(s) I want considered for license release (list all Butte County cases holding your driver’s license
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 will 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 reverse for details.)
Complete either Section A or B as directed:
A. I certify that I receive the following public assistance (check all that apply and attach proof):
Supplemental Security Income/SSI
County relief, 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 Program)
Rev. 9/24/2015
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