Traffic Tickets-Infractions Amnesty Program Participation Form {TUO-TF-200}

TUO-TRF-200 SUPERIOR COURT OF CALIFORNIA COUNTY OF TUOLUMNE 60 North Washington Street Sonora, CA 95370 Phone: (209) 533-5671 The People of the State of California, Plaintiff, vs. Case Number: Space below for use of Court Clerk only Defendant. Citation Number: TRAFFIC TICKETS/INFRACTIONS AMNESTY PROGRAM PARTICIPATION FORM (October 1, 2015 to March 31, 2017) Date: _______________________ Driver's License Number: ___________________ State: ______________ Name: _________________________________ Email: ___________________________________________ Current Address: __________________________________________________________________________ Contact Number(s): Home: __________________ Mobile: ___________________ Work: ________________ 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: I do not owe restitution to a victim in Tuolumne County. I do not have any outstanding misdemeanor or felony warrants in Tuolumne County. I made no payments to the court, county, or collecting entity for the eligible violation after Sept. 30, 2015. In order to be eligible for the restoration of my driver's license, I declare one or both of the following is true: I have appeared and satisfied all my court-ordered obligations in Tuolumne County. I am a person in good standing with, 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 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 readjusted or full amount. (See reverse for details.) TRAFFIC TICKETS/INFRACTIONS AMNESTY PROGRAM PARTICIPATION FORM (October 1, 2015 to March 31, 2017) ________________________________________________________________________________ Form Adopted for Local Use - Local Rules of the Superior Court of California TUO-TRF-200 (Amended October 15, 2015) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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 County relief, general relief, or general assistance State Supplementary Payment/SSP Cash Assistance Program for Immigrants (CAPI) CalFresh (Supplemental Nutrition Assistance 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 readjusted or full amount. Signature _________________________________________ PLEASE NOTE THE FOLLOWING: CalWORKs Medi-Cal In-Home Supportive Services (IHSS) Tribal Temporary Assistance for Needy Families (TANF) Date _____________________________ What will happen if you are not eligible for the 50% amnesty reduction? If, after this form is submitted, the court/county/collecting entity discovers you are not eligible for amnesty because you have 1 or more outstanding warrants or owe victim restitution in this county, you shall be notified within 10 business days that your form is being suspended. You will then have 20 business days to bring written proof to the court/county/collecting entity that the outstanding warrant(s) and/or victim restitution issues have been addressed. On the 21st business day, or earlier if the information you provide does not demonstrate you are eligible for amnesty, the court/county/collecting entity will retroactively cancel the amnesty program, restore previously reduced court-ordered amounts, and credit any paid amounts toward your revised outstanding debt. The court/county/collecting entity will send you notice of this action to the address indicated on this document. What will happen if you are not eligible for the 80% amnesty reduction? If, after this form is submitted, the court/county/collecting entity discovers you are not eligible for the 80 percent reduction in bail/fines/fees because you are not receiving public assistance as listed or because your household income is not at or below 125 percent of the federal poverty rate, you shall be notified within 10 business days that your amnesty discount will be revised. You will then have 20 business days to bring written proof to the court/county/collecting entity that you do receive the specified public assistance or that your income is not at or below 125 percent of the federal poverty rate for your household. On the 21st business day, or earlier if the information you provide does not demonstrate that you are eligible for the 80 percent discount, the court/county/collecting entity will determine whether to revise the discount, if you are eligible, to 50 percent of the amount owed for court-ordered debt or impose the full amount as discussed above and credit any paid amounts toward your revised outstanding debt. The court/county/collecting entity will send you notice of this action to the address indicated on this document. ________________________________________________________________________________________ FOR USE ONLY BY COURT/COUNTY OFFICE OF REVENUE RECOVERY Citation/Fine due date: ________________________ Total outstanding balance: $___________________ Case number: _______________________________ Amnesty payment due: $______________________ The County of Tuolumne OR the Superior Court of Tuolumne County (or designated agent) has verbally verified case eligibility for the Amnesty Program and has determined the following: Eligible for: 50% reduction Full Payment 80% reduction Payment Plan 50% reduction Driver's License Reinstatement 80% reduction Driver's License Reinstatement Not Eligible for (check all that apply): Certified by: ___________________________________________ Title: _____________________________