Statewide Traffic Tickets Infractions Amnesty Program 2015
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1Statewide Traffic Tickets/Infractions Amnesty Program 2015
SAN FRANCISCO SUPERIOR COURT - Participation Form
Date:
Driver’s License Number:
State:
Name:
AKAs:
Date of Birth:
Social Security #:
Email Address:
Address:
City:
State:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Address:
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 in a case 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 after September 30, 2015 for the eligible violation(s) where the citation
issued on or before January 1, 2013.
In order to be eligible for the restoration of my driver’s license only, I declare one of the following is true:
I will pay my debt in full or enter into a payment plan to satisfy the debt on the eligible violation(s) once the amount due has been
determined.
I am currently in good standing and making timely payments pursuant to an approved payment plan on the eligible violation(s).
By signing below, I affirm that I understand each of the following:
•
I do not want to protest any open (unadjudicated) infraction citations I have in San Francisco County that would otherwise
qualify under this Amnesty Program.
•
The Court’s contracted collections vendor (Alliance One) will contact me regarding my eligibility, total amount due, and payment
plan enrollment at the address/phone information I provided above.
•
The San Francisco Superior Court will review this application and research for additional citations I have outstanding in San
Francisco County. The Court will provide Alliance One all eligible citation numbers and amounts due. If approved, Alliance One
will determine my eligibility for a 50% or 80% reduction on the total amount due, and contact me to pay the amount due in full
or arrange a payment plan and collect the $50 amnesty fee plus first installment payment. Upon receipt of payment in full
(including the $50 amnesty fee) or the first installment payment on a payment plan and $50 amnesty fee, Alliance One will
notify the San Francisco Superior Court to contact the DMV to remove the hold placed on my license for citations issued in San
Francisco County. (I will need to contact the DMV to pay any fees to have my license reinstated per DMV policy.)
•
If deemed ineligible for any reason, I may remedy the ineligibility and reapply for amnesty during the length of the program.
•
I must pay the determined balance owed in full at this time or comply with terms of the approved payment plan.
•
I must pay the 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 will be responsible for payment of any re-adjusted or full amount.
TO DETERMINE APPLICABLE REDUCTION, IF QUALIFIED, PLEASE COMPLETE THE FOLLOWING:
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 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.
By checking this box, I give permission for (agency)_______________________________ to contact Alliance One on my behalf.
Signature:
Date:
v. October 1, 2015
Return this form to: Alliance One, 6160 Mission Gorge Rd., Suite 300 San Diego, CA 92120
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