Application For Review Of Civil Assessment [penal Code 1214.1] And/or Delinquent Fine Payments Form
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1
2SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF NEVADA
201 Church Street, Suite 7, Nevada City, CA 95959
(530) 265-1311
10075 Levon Avenue, Suite 107, Truckee, CA 96161
(530) 582-7835
PEOPLE OF THE STATE OF CALIFORNIA ,
APPLICATION FOR REVIEW OF CIVIL
vs
ASSESSMENT [Penal Code § 1214.1]
AND/OR DELINQUENT FINE PAYMENTS
Defendant: _____________________________________
Case Number____________________
1.
REQUEST TO VACATE CIVIL ASSESSMENT/FAILURE TO PAY FINE
IMPORTANT: Written proof of any of the following that supports your explanation for failing to pay the
fine ordered must be attached or your application will be returned.
HOSPITALIZED
RESIDENTIAL TREATMENT
NOT PERSON CITED
INCARCERATED
DEATH CERTIFICATE
CLERICAL ERROR
MILITARY DUTY
OTHER EVIDENCE OF EXTRAORDINARY CIRCUMSTANCES
The following is an explanation of my failure(s) to pay the fine ordered:
(Please print and include mandatory supporting attachments.)
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
2.
REQUEST FOR REVIEW OF DELINQUENT FINE PAYMENTS
I am requesting the following relief:
New payment amount ($ _________/mo.)
New payment start date (___/___/___)
Pay fine with community service @ $10/hr. NOTE: Civil Assessment cannot be satisfied with community service.
Pay in full without Civil Assessment on ___/___/___.
Convert fine to jail time (misdemeanors and felonies only). NOTE: Civil Assessment cannot be converted to jail time.
Release hold on license
Other:
-
______________
Please state why you are making this request and list the facts in support of your request below:
_____________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Attached number of pages: _____
I declare under penalty of perjury under the laws of the State of California that all of the foregoing information, and all
attachments, are true and correct to the best of my knowledge.
Executed at _______________________________ on _____________________
City and State
Date
Address ___________________________________________________________________________________________
Telephone # __________________________________
Signature: __________________________________________
Note: It is mandatory to list all contact information requested.
APPLICATION FOR REVIEW OF CIVIL ASSESSMENT [Penal Code § 1214.1] AND/OR DELINQUENT FINE PAYMENTS
H:\SHARED\Criminal\Forms\CA-Application&OrderforReviewCA-DFP (rev 122314)
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