Request To Address Civil Assessment For Failure To Appear Or Pay printable pdf download

Request To Address Civil Assessment For Failure To Appear Or Pay

Attorney or Party Without An Attorney (Name, State Bar No. & Address)

FOR COURT USE ONLY

Telephone No.

Attorney for:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO

NAME OF COURT:

STREET ADDRESS:

MAILING ADDRESS:

CITY, STATE ZIP:

DISTRICT NAME:

PEOPLE OF THE STATE OF CALIFORNIA

vs.

DEFENDANT:

CASE NUMBER

REQUEST TO ADDRESS CIVIL ASSESSMENT FOR

FAILURE TO APPEAR/PAY PURSUANT TO PC1214.1(a)

In accordance with Penal Code section 1214.1(a), the Court imposed a Civil Assessment to your case in lieu of issuing a warrant.

Note: Only one request to address this civil assessment may be filed. You have the following options to address the Civil

Assessment:

OPTION 1: Establish Payment arrangements (No court appearance required):

You may establish payment arrangements. (If this option is selected, I will be required to pay a $35.00 administrative

fee). Please contact the court at the above address or Court Compliance at (909) 387-1470.

OPTION 2: Submit a “good cause” statement and attach supporting documents. (Court appearance may be

required):

You must show good cause (explain in writing the circumstance beyond your control) as to why you failed to appear or pay;

and you must attach documentation to support the explanation which includes written proof of the following:

A. Medical Incapacitation/Hospitalization. I have attached proof of incapacitation/hospitalization

from _____________ to ______________.

B. Incarceration. I have attached proof of incarceration from ______________ to ______________.

C. Military Orders. I have attached proof of military orders from ______________ to ______________.

IMPORTANT: Attach copies only as written proof, originals will not be returned to you.

OPTION 3: In the event none of the circumstances in Option 2 apply, submit a “good cause” statement and attach

supporting documents. (Court appearance may be required):

Good Cause Statement: I failed to appear in court or I had good reason for not paying my fine (other than those reasons

listed in option 2) when due. Explain the circumstance/reason that prevented you from responding within the specified time

period:

I have attached the supporting document(s) from _________________ to ________________.

I understand that I may be ordered to appear in court to explain these circumstances.

I declare under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge and that

written proof is attached to this form as required.

SIGNATURE OF DEFENDANT

DATE

OTS-CRTIAE-RC-20130904

Page 1 of 2

REQUEST TO ADDRESS CIVIL ASSESSMENT FOR

FAILURE TO APPEAR/PAY PURSUANT TO PC1214.1(a)

Form #21288

Request To Address Civil Assessment For Failure To Appear Or Pay

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