Infraction Request Form {SB-16350}

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO STREET ADDRESS: CITY AND ZIP CODE: DISTRICT NAME: FOR COURT USE ONLY People of the State of California ­v- Name: Date of Birth: INFRACTION REQUEST FORM Case or Citation No. Do not use this form if you want your fine or payments to be lowered or you want to do community service instead of paying a fine. For those requests, use a Request for Consideration of Ability to Pay form. If you have documents to attach to this form, they must be attached at the time you file this with the court. If you attach confidential information, such as medical or financial records, write "CONFIDENTIAL" at the top of those pages. Make sure that social security numbers and bank account numbers cannot be seen on your attachments. What are you asking the court to do? Grant me an extension to: Modify a previous sentence: Appear Allow traffic school Pay Allow monthly payments Complete traffic school Change the day of the month payment is due Complete community service Submit proof of correction Or: Other: _________________________________________________________________________________________ __________________________________________________________________________________________________ (If additional space is needed, please attach another page) I have good cause for my failure to appear failure to pay. Documentation is attached to confirm my: Medical Incapacitation/Hospitalization Military service Incarceration Other good cause: ________________________________________________________________________________ __________________________________________________________________________________________________ (If additional space is needed, please attach another page) I declare under penalty of perjury, under the laws of the State of California, that the information on this form and any attachments are true and correct. ___________________ _________________________________________ DATE PRINTED NAME _______ SIGNED NAME ______ NOTICES You may be required to appear in court regarding your request. You will be notified in writing if your personal appearance has been ordered. Additional, non-refundable fees may be added to your case, as listed below: $60.00 Traffic school administration fee (VC§11205.2/42007.1) $35.00 Installment agreement fee (VC§ 40510.5) $30.00 Fee for payment extensions (PC§ 1305(e)) Failure to resolve your citation by the due date may result in additional actions being taken on your case. This may include a civil assessment of up to $300.00 pursuant to PC§ 1214.1, assignment to a collection agency, and/or a hold being placed on your driver's license that may result in the suspension of your driving privileges. Failure to pay your fine after making a payment agreement or being ordered to pay a fine by the Court may result in the addition of a civil assessment of up to $300.00 being added to your case and/or assignment to a collection agency. www.FormsWorkFlow.com Form SB-16350 Rev 9/13/17 Page 1 of 1