Declaration Of Financial Circumstances For Community Service {TR-02}

CONFIDENTIAL Name, address and telephone number of attorney or party without attorney: FOR COURT USE ONLY Telephone No.: Fax No.: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SUTTER STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 1175 Civic Center Boulevard 1175 Civic Center Boulevard Yuba City, CA 95993 PEOPLE OF THE STATE OF CALIFORNIA, VS. DEFENDANT: DECLARATION OF FINANCIAL CIRCUMSTANCES FOR COMMUNITY SERVICE OR ABILITY TO PAY TRAFFIC FINE CASE NUMBER: 1. Why are you asking the court to allow you to perform community service or reduce your traffic fine? I receive (check all that apply): Medi-Cal Food Stamps SSI / SSP CalWORKS IHSS (In-Home Supportive Services) General Assistance 2. HOUSEHOLD MEMBERS FOR WHOM YOU PROVIDE SUPPORT Age Relationship Age a) d) b) e) c) f) Relationship 3. HOUSEHOLD INCOME, EXPENSES, & EMPLOYMENT INFORMATION MONTHLY INCOME: MONTHLY EXPENSES: Gross monthly income (all sources) $ Rent or Mortgage SSI / AFDC $ Food Less Mandatory Deductions $ Clothes Less Garnishments $ Transportation Utilities Net Monthly Income $ Medical / Dental Employer: Child Care / Support Occupation: Address: Total $ $ $ $ $ $ $ $ I declare, under penalty of perjury, that the foregoing information is true and correct Dated: (TYPE OR PRINT NAME) (SIGNATURE) (ADDRESS) (CITY, STATE & ZIP CODE) (TELEPHONE NUMBER) (SOCIAL SECURITY NUMBER) You are signing your request under penalty of perjury; you must answer truthfully and accurately. The Court may ask you for information or evidence. You may be ordered to go to court and answer questions about your ability to pay court obligations and to provide proof that you are eligible for the Community Service Program or have the ability to pay the traffic fine. You may also be ordered to pay if it is later determined that you were not eligible for Community Service or had the ability to pay the traffic fine. Local Form Approved for Optional Use Sutter County Superior Court Effective: August 1, 2014 Revised: June 29, 2016 DECLARATION OF FINANCIAL CIRCUMSTANCES FOR COMMUNITY SERVICE OR ABILITY TO PAY TRAFFIC FINE TR-02 Page 1 of 1 Penal Code §1209.5 American LegalNet, Inc. www.FormsWorkFlow.com