Declaration And Application By Defendant PC 1203.4-1203.4a {SC-3004}

ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS): TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR (NAME): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA STREET ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF: DEFENDANT: People of the State of California ____________________________________________________________ PRINT OR TYPE DEFENDANTS NAME Declaration and Application for Change of Plea and Request for Dismissal (PC § 1203.4/1203.4a) 1. 2. CASE NUMBER: My date of birth is __________________________________. My driver's license number is __________________________________. On the date of __________________________________________, I was convicted of the misdemeanor/infraction offense(s) of violation of section(s) ______________________________________________________________________________________________________. I was: (check one) (1203.4) placed on probation, and I have fulfilled all the conditions of probation for the entire time required. (1203.4a) sentenced more than one year ago, without probation, and I have fully complied with the sentence. 3. 4. I am not now charged with, serving a sentence for, or on probation for any offense. Since being sentenced or placed on probation in this case, I have lived an honest life, have conformed to and obeyed the laws of the land, and have not been convicted, arrested, or given a citation (ticket) except _____________________________________________________________________________________________________________. I request that the conviction be set aside, that a plea of not guilty be entered, and that the Court dismiss this action pursuant to the provisions of section 1203.4/1203.4a of the Penal Code. I understand that the requested dismissal: (a) will not affect any revocation or suspension of my driving privilege, (b) will not prevent this conviction from being pled to and proved in any subsequent prosecution, and (c) will not relieve me of the obligation to disclose the conviction in response to a direct question in any questionnaire or application for public office, for licensure by any state or local agency, or for contracting with the California State Lottery. Fee Waiver request ­ If you cannot afford to pay court fees and costs, you may not have to pay them. If you are receiving public benefits, are a low-income person, or do not have enough income to pay for your household's basic needs and the court fees, you may ask the court to waive all or part of your court fees. To make a request to the court to waive your fees in superior court, complete the Request to Waive Court Fees (form FW-001) and attach to this form. 5. 6. 7. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signed on _____________________________________________ at _______________________________________________, California. Date Signature of Defendant Street Address City DO NOT WRITE BELOW THIS LINE - FOR COURT USE ONLY Place Print or Type Defendant's Name State Zip Code YOU MUST APPEAR IN COURT ON: ___________________________________ TIME: ____________ DEPT: ____________ District Attorney notified on ________________________ by ______________________________, Deputy CII and DMV processed on ________________________ by ______________________________, Deputy ORDER The declaration and application by defendant is Granted Pursuant to Penal Code section 1203.4/1203.4a, it is so ordered that the conviction be set aside, a plea of not guilty be entered, and the complaint dismissed upon payment of any fee imposed by the court on this order. Pay fee in the amount of $50.00 (court costs) and $7.00 (county costs) to the Court by ________________________. Pay fee in the amount of $_________ (court costs) and $ _________ (county costs) to the Court by ________________________. No fee imposed. Denied ___________________________________________________________________________________________________ Dated: _______________________ SC-3004 [Rev. June 2015] _____________________________________________________ Judge of the Superior Court Declaration/Application for Change of Plea/Dismissal PC 1203.4/1203.4a American LegalNet, Inc. www.FormsWorkFlow.com