Infractions Amnesty Program Participation Form
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1
2Traffic Tickets/Infractions Amnesty Program
Participation Form – Stanislaus County Revenue Recovery
October 1, 2015 to March 31, 2017
Driver’s License Number: ____________________ Date of Birth:_________________
Name: _______________________________________________________________
Current Address: _______________________________________________________
Contact Number(s): Home: ____________ Mobile:___________ Work:____________
Cases: _______________________________________________________________
_______________________________________________________________
Employer’s Name: ______________________________________________________
Employer’s Address:_____________________________________________________
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:
□
Neither I nor my minor children owe restitution to a victim within the County of Stanislaus.
□
I do not have any outstanding misdemeanor or felony warrants in the county where the violation occurred.
□
I made no voluntary or involuntary payments to Stanislaus County Revenue Recovery or the Franchise Tax Board
for the 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.
□
st
I am currently making payments to the court, county, or a collecting entity for tickets dated 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 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):
□
□
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
Medi‐Cal
Program)
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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