SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PLAINTIFF:
PEOPLE OF THE STATE OF CALIFORNIA
DEFENDANT:
FOR COURT USE ONLY
CIVIL ASSESSMENT PETITION AND ORDER
Defendant’s Request and Declaration to Vacate Civil Assessment
CASE NUMBER:
IMPORTANT: Written proof of any of the following must be attached and cover the time period in question.
HOSPITALIZED OVERSEAS MILITARY DUTY
INCARCERATED OTHER
The following is an explanation of my failure to pay. (Please print in English only.)
I declare under penalty of perjury that the foregoing statement is true and correct to the best of my knowledge and
that written proof is attached to this form.
Executed at on
(City and State) (Date)
RESERVED FOR CLERK’S FILE STAMP
Address
Telephone Number:
Signature:
ORDER RE CIVIL ASSESSMENT (COURT USE ONLY)
The Court having read and considered the Petition regarding vacating the Civil Assessment pursuant to
PC 1214.1(B), hereby makes the following order:
Petition to vacate is:
Denied Granted
Signature Date
(Judicial Officer)
If your petition is granted, the Department of Revenue will be notified for refund of the Civil Assessment fee. You
may contact them at:
MAIL ADDRESS: OFFICE ADDRESS:
P.O. Box 1897 1555 Berger Drive, Bldg. #2
San José, CA 95109-1897 San José, CA
Telephone: (408) 282-3200
CR-6058 REV 8/
12
CIVIL ASSESSMENT PETITION AND ORDER Page 1 of 1
(CRIMINAL)
