If you can't afford to pay your fine, fill out this form to ask for a
lower fine, a payment plan, more time to pay, and/or community
Using this form
Use this form after the court has decided that you owe the fine.
You may use this form even if your fine has been sent to
collections. If you have more than one fine, use one form for
each fine.
Mail or take this form to the court listed on your ticket. If you
want to file the form electronically, ask the court if it allows
Clerk stamps date here when form is filed.
Superior Court of California, County of
Fill in the case number and ticket number (if you
have it):
Case Number:
Fill in court name and street address:
Ticket Number:
Can't Afford to Pay Fine:
Traffic and Other Infractions
Your information
Street or mailing address:
State Zip
Judicial Council of California, www.courts.ca.gov
New April 1, 2018, Optional Form
Vehicle Code § 42003(c), Penal Code 1214.1,
California Rules of Court rules 4.106(c) and 4.335
Can't Afford to Pay Fine:
Traffic and Other Infractions
Page 1 of 3
If you lost your ticket or have questions, contact your court
Use this form for traffic fines (like speeding) or other infractions
(like fishing without a license or drinking in public).
Types of fines
This form is not for parking tickets. Read your parking ticket
to find out what you can do.
Do not use this form to tell the court that you didn't do anything wrong. See the instructions on your ticket and visit
www.courts.ca.gov/selfhelp.htm for more information on fighting it.
* OK to text you at this number?
Email (optional):
* OK to email you at this email?
* Some courts don't use text messages and email to contact court clients. Message and data rates would apply.
What type of income do you have?
I get public benefits. (Check all that apply, then skip to )
I do not get money from any source. (Skip to )
Supplemental Security Income (SSI)
In-Home Supportive Services (IHSS)
State Supplementary Payment (SSP)Food stamps (CalFresh)
County Relief/General Assistance Medi-Cal
CalWORKs or Tribal TANF
Cash Assistance Program for Immigrants (CAPI)
Other need-based aid
This money supports me and other people.
Case Number:
New April 1, 2018
Can't Afford to Pay Fine:
Traffic and Other Infractions
Page 2 of 3
I do not get public benefits, but I get money from other sources. (Answer all that apply)
How much money do you earn (take-home pay) or get from other sources (including income received in your
family from a spouse or live-in romantic partner)?
$ every: (Check one)
Year 2 weeks Twice a month
Week Month Season
If I pay the fine, I would: (Check all that apply, if any)c.
Not have enough money to pay my rent/mortgage. I pay for rent/mortgage every
(Check one):
Not have enough money to pay for other basic living expenses. Basic living expenses are things like: food,
utilities, childcare, child support, transportation, medication, insurance (medical, car, house, and rental),
and student loans.
Not have enough money to pay my debt for other court cases.
Have other problems (please explain):
Do you have anything that shows your public benefits, income, or expenses?
Yes, I have attached copies to this form.
Things like an EBT card, paystubs, tax returns, rent or mortgage checks, or utility bills.
Important! Keep the original documents for your own records. Any copies you attach can be destroyed after
the court makes a decision on your case. Cross out any social security numbers, or other private information,
on the copy you give the court.
I do not have any papers to show because:
Have you told the court before that you can't pay this fine?
No, not that I can rememberYes
(Skip to )
What has changed in your family's life since then? (Check all that apply, if any.)
Suffered a serious illness or disability.
Started to receive public benefits.
Lost job or reduced hours at work.
Case Number:
New April 1, 2018
Can't Afford to Pay Fine:
Traffic and Other Infractions
Page 3 of 3
What are you asking the court to do? (Check all that you are willing and able to do)
Lower the amount I owe on the fine.
Not all courts offer all of these choices.
Contact the court listed on your ticket to
find out about your choices.
Some fines can't be reduced just
because you don't have the money to
pay them. You may ask for more time
to pay, community service, and/or
monthly payments even if the court
can't reduce the fine.
Payment plan: I want to pay:
$ every month on the
day of the month,
until this fine is paid off.
More time to pay: Please change my
deadline to (month/day/year):
Community service instead of
paying the fine. I understand that
community service may not be
available on weekends or evenings.
Cancel or lower late charges that I have for missing a hearing or failing to pay my fine on time.
Other information:
List other facts (if any) about why you can't pay the fine or about your choices in . (You can add extra pages or
attach other documents that help you explain)
Driver's license "hold" or suspension
Did you miss a court date or fail to pay a fine? If so, the Department of Mortor Vehicles (DMV) might have
suspended or put a "hold" on your driver's license. If the court clears your failure to appear or failure to pay, the
court can notify the DMV. You must still contact the DMV to get your license back.
Read and sign below
I promise that the information above is correct. I declare under penalty of perjury, under the laws of
the State of California, that all information on or attached to this form is true.
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