Proof of Service - LA Law Library - Home Page · being a victim of human trafficking ... and vacated and a plea of not guilty be entered and that the complaint ... not guilty by reason

Name

Address

Phone #

DOB

Employer Name

Employer Add.

Position/Title

Case Number

Name on Case

Date of Conviction

Last Name

Code

Section

17(b)Fel/Misd/Inf

Case Number

Section 4 - 647(b) 1203.49

5B My gross monthly household income is less than the amount listed below

5C I do not have enough income to pay for my households basic needs and the court fees

and ask the court to waive: All fees

Section 2 - 1203.4 Probation

Case & Conviction Info

Proof of Service

City Zip

FEE WAIVER INFORMATION

Food Stamps SSI Medi-Cal GR CalWorks/Tanf IHSS CAPI SSP

PARTICIPANT GENERAL INFORMATION

5A Receive gov benefit

2a - Met terms/conditions

2b - Early Termination

2c - Interests of Justice

Section 3 - M/Inf 1203.4a

3a - Mandatory

3b- Interests of Justice

Convicted of PC 647(b) as a result of being a victim of human trafficking

County

Court of Conviction

Prosecutor

Section

Name of Server

City mailed from

Residence orBusiness Address

Date Mailed

Check one of the following:

Deposited with U.S. Postal Service with Postage

Placed and mailed following ordinary business practices

Case Notes

Developed by: Dehsong Matheu & James Matheu

Common PathCalifornia

Family Size Family Income Family Size Family Income Family Size Family Income 1 $1,256 3 $2,127 5 $2,998 2 $1,692 4 $2,563 6 $3,433

Add $435 foreach personafter 6

State

17(d)(2)felony reduction to misdemeanor

misdemeanor reduction to infraction

(Penal Code, Vehicle Code, H&S Code, etc.,) Section 5 - Realignment 1203.41

5a - with supervision

5b - straight jail

Form Approved for Optional Use Judicial Council of California MC-031 [Rev. July 1, 2005]

ATTACHED DECLARATION

PLAINTIFF/PETITIONER: CASE NUMBER:

DEFENDANT/RESPONDENT:

MC-031

(This form must be attached to another form or court paper before it can be filed in court.)

DECLARATION

Date:

(SIGNATURE OF DECLARANT)(TYPE OR PRINT NAME)

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Plaintiff

Other (Specify):

DefendantAttorney for Petitioner

Respondent

Page 1 of 1

CR-180

PEOPLE OF THE STATE OF CALIFORNIAv.

DATE OF BIRTH:DEFENDANT:

FOR COURT USE ONLY

CASE NUMBER:

PETITION FOR DISMISSAL (Pen. Code, §§ 17(b), 17(d)(2), 1203.4, 1203.4a, 1203.41, 1203.49)

FOR COURT USE ONLY Date: Time:Department:

ATTORNEY OR PARTY WITHOUT ATTORNEY:

STATE: ZIP CODE:CITY:

STREET ADDRESS:

FIRM NAME:

NAME:

STATE BAR NO.:

TELEPHONE NO.: FAX NO.:

E-MAIL ADDRESS:

ATTORNEY FOR (name):

should be granted relief in the interests of justice. (Please note: You must explain why granting a dismissal would be in the interests of justice. You may complete and attach the Attached Declaration (form MC-031) or submit other relevant documents.)

b.

has lived an honest and upright life since pronouncement of judgment and conformed to and obeyed the laws of the land; or

(date):On , the petitioner (the defendant in the above-entitled criminal action) was convicted of a violation of the following offenses:

a.

Code Section Type of offense: (Felony;Misdemeanor; Infraction)

Eligible for reduction to misdemeanor under Penal Code § 17(b) (Yes or No)

Eligible for reduction to infraction under Penal

Code § 17(d)(2) (Yes or No)

If additional space is needed for listing offenses, use Attachment to Judicial Council Form (form MC-025).

1.

a.

b.c.

2. Felony or misdemeanor with probation granted (Pen. Code, § 1203.4)

has fulfilled the conditions of probation for the entire period thereof;has been discharged from probation prior to the termination of the period thereof;

should be granted relief in the interests of justice. (Please note: You must explain why granting a dismissal would be in the interests of justice. You may complete and attach the Attached Declaration (form MC-031) or submit other relevant documents.)

3. Misdemeanor or infraction with sentence other than probation (Pen. Code, § 1203.4a)Probation was not granted; more than one year has elapsed since the date of pronouncement of judgment. The petitionerhas complied with the sentence of the court and is not serving a sentence for any offense or under charge of commission ofany crime; and the petitioner (check one):

Form Approved for Optional Use Judicial Council of California CR-180 [Rev. January 1, 2017]

PETITION FOR DISMISSAL Penal Code, §§ 17(b), 17(d)(2), 1203.4, 1203.4a, 1203.41, and 1203.49

www.courts.ca.gov

Probation was granted on the terms and conditions set forth in the docket of the above-entitled court; the petitioner is notserving a sentence for any offense, nor on probation for any offense, nor under charge of commission of any crime, andthe petitioner (check all that apply):

Page 1 of 2

Petitioner requests that he/she be permitted to withdraw the plea of guilty, or that the verdict or finding of guilt be set aside and a plea of not guilty be entered and the court dismiss this action under section:

1203.4a1203.4


Executed on:

(ADDRESS, PETITIONER) (CITY) (STATE) (ZIP CODE)

(DATE)

u(SIGNATURE OF PETITIONER OR ATTORNEY)

Page 2 of 2 PETITION FOR DISMISSAL

Petitioner requests that the eligible felony offenses listed above be reduced to misdemeanors under Penal Code section 17(b) and eligible misdemeanor offenses be reduced to infractions under Penal Code section 17(d)(2).

5. Felony county jail sentence under Penal Code section 1170(h)(5) (Pen. Code, § 1203.41)Petitioner is not under supervision under Penal Code section 1170(h)(5)(B) and is not serving a sentence for, on probation for, or charged with the commission of any offense, and should be granted relief in the interests of justice, and (check one):

more than one year has elapsed since petitioner completed the felony county jail sentence with a period of mandatory supervision imposed under Penal Code section 1170(h)(5)(B); or

a.

more than two years have elapsed since petitioner completed the felony county jail sentence without a period of mandatory supervision imposed under Penal Code section 1170(h)(5)(A).

b.

(Please note: You must explain why granting a dismissal would be in the interests of justice. You may complete and attach the Attached Declaration (form MC-031) or submit other relevant documents.)

4. Misdemeanor conviction under Penal Code section 647(b) (Pen. Code, § 1203.49)Petitioner has completed a term of probation for a conviction under Penal Code section 647(b).Petitioner should be granted relief because the petitioner can establish by clear and convincing evidence that the convictionwas the result of his or her status as a victim of human trafficking. (Please note: You may complete and attach the AttachedDeclaration (form MC-031) or submit other relevant documents to establish that the conviction was the result of your statusas a victim of human trafficking.)

1203.49 of the Penal Code.1203.41

CASE NUMBER:PEOPLE OF THE STATE OF CALIFORNIA v. DEFENDANT:CR-180

CR-180 [Rev. January 1, 2017]

For your protection and privacy, please press the Clear This Form button after you have printed the form.

a.b.

6.

7.

8.

Deferred entry of judgment (Pen. Code, § 1203.43)Petitioner performed satisfactorily during the period in which deferred entry of judgment was granted. The criminal charge(s) were dismissed under Penal Code section 1000.3 on (date): .Furthermore (check one):

court records are available showing the case resolution.a.

petitioner declares under penalty of perjury that the charges were dismissed after he or she completed therequirements for deferred entry of judgment. Petitioner (check one)

b.

1203.43

has

has not

attached a copy of his or her state summary criminal history information.

The court GRANTS the petition for dismissal regarding the following convictions under Penal Code and it is ordered that the pleas, verdicts, or findings of guilt be set aside

and vacated and a plea of not guilty be entered and that the complaint be, and is hereby, dismissed for:

Form Approved for Optional Use Judicial Council of California CR-181 [Rev. January 1, 2017]

ORDER FOR DISMISSAL Page 1 of 2

Penal Code, §§ 17(b), 17(d)(2), 1203.4, 1203.4a, 1203.41, 1203.43and 1203.49

www.courts.ca.gov

CR-181

PEOPLE OF THE STATE OF CALIFORNIAv.

DATE OF BIRTH:DEFENDANT:

ORDER FOR DISMISSAL (Pen. Code, §§ 17(b), 17(d)(2), 1203.4, 1203.4a, 1203.41, 1203.49)

FOR COURT USE ONLY

CASE NUMBER:

ATTORNEY OR PARTY WITHOUT ATTORNEY:

STATE: ZIP CODE:CITY:

STREET ADDRESS:

FIRM NAME:

NAME:

STATE BAR NO.:

TELEPHONE NO.: FAX NO.:

E-MAIL ADDRESS:

ATTORNEY FOR (name):

1. The court GRANTS the petition for reduction of a felony to a misdemeanor (maximum punishment of 364 days per Pen. Code,§ 18.5) under Penal Code section 17(b) and/or for reduction of a misdemeanor to an infraction under Penal Code section17(d)(2) and reduces the following convictions:

The court finds from the records on file in this case, and from the foregoing petition, that the petitioner (the defendant in the above-entitled criminal action) is eligible for the following requested relief:

ALL FELONY CONVICTIONS in the above-entitled action;

Only the following convictions in the above-entitled action (specify charges and date of conviction):

2. The court DENIES the petition for reduction of a felony to a misdemeanor under Penal Code section 17(b) and/or for reduction of amisdemeanor to an infraction under Penal Code section 17(d)(2) for:

ALL FELONY CONVICTIONS in the above-entitled action;

Only the following convictions in the above-entitled action (specify charges and date of conviction):

3.

ALL CONVICTIONS in the above-entitled action; orOnly the following convictions in the above-entitled action (specify charges and date of conviction):

4. The court DENIES the petition for dismissal regarding the following convictions under Penal Code

ALL CONVICTIONS in the above-entitled action; orOnly the following convictions in the above-entitled action (specify charges and date of conviction):

§ 1203.41, or§ 1203.4, or

§ 1203.41, or§ 1203.4a, or § 1203.49,§ 1203.4, or

§ 1203.4a, or § 1203.49 for:

ALL MISDEMEANOR CONVICTIONS in the above-entitled action; OR

ALL MISDEMEANOR CONVICTIONS in the above-entitled action; OR

FOR COURT USE ONLY

(JUDICIAL OFFICER)

If the order is granted under the provisions of either Penal Code section 1203.4, 1203.4a, 1203.41, or 1203.49, the petitioner is released from all penalties and disabilities resulting from the offense except as provided in Penal Code sections 29800 and 29900 (formerly sections 12021 and 12021.1) and Vehicle Code section 13555. In any subsequent prosecution of the petitioner for any other offense, the prior conviction may be pleaded and proved and shall have the same effect as if probation had not been granted or the accusation or information dismissed. The dismissal does not permit a person to own, possess, or have in his or her control a firearm if prevented by Penal Code sections 29800 or 29900 (formerly sections 12021 and 12021.1). Dismissal of a conviction does not permit a person prohibited from holding public office as a result of that conviction to hold public office.

8.

9. In addition, as required by Penal Code section 299(f), relief under Penal Code sections 17(b), 17(d)(2),1203.4, 1203.4a, 1203.41, or 1203.49 does not release petitioner from the separate administrativeduty to provide specimens, samples, or print impressions under the DNA and Forensic IdentificationDatabase and Data Bank Act (Pen. Code, § 295 et seq.) if petitioner was found guilty by a trier of fact,not guilty by reason of insanity, or pled no contest to a qualifying offense as defined in Penal Codesection 296(a).

Date:

CASE NUMBER:PEOPLE OF THE STATE OF CALIFORNIA v DEFENDANT:CR-181

Page 2 of 2 CR-181 [Rev. January 1, 2017] ORDER FOR DISMISSAL

6. If this order is granted under the provisions of Penal Code section 1203.4 or 1203.41:

The petitioner is required to disclose the above conviction in response to any direct question contained in any questionnaire or application for public office, or for licensure by any state or local agency, or for contracting with the California State Lottery Commission; and

Dismissal of the conviction does not automatically relieve petitioner from the requirement to register as a sex offender. (See, e.g., Pen. Code, § 290.5.)

a.

b.

If the order is granted under the provisions of Penal Code section 1203.49, the Department of Justice is hereby notified that the petitioner was a victim of human trafficking when he or she committed the crime, and the relief ordered.

7.


10. The basis for an order of dismissal granted under the provisions of Penal Code section 1203.43 is theinvalidity of defendant's prior plea due to misinformation in Penal Code section 1000.4 regarding theactual consequences of making a plea and successful completion of a deferred entry of judgmentprogram.

5. In granting this order under the provisions of Penal Code section 1203.4, the court finds that the petitioner was a victim of humantrafficking when he or she committed the crime. The court orders (check one)

The court orders the relief described in section 1203.4, or

The court orders the relief described in section 1203.4, with the following exceptions (specify):

a.

b.

PLAINTIFF:PEOPLE OF THE STATE OF CALIFORNIA

DEFENDANT:

DECLARATION RE: ABILITY TO PAY COSTS FOR PETITION AND ORDER FOR EXPUNGEMENT PC § 1203.4

RESERVED FOR CLERKS FILE STAMP

CASE NUMBER:

SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES

COURTHOUSE ADDRESS:

I have the ability to pay the $ _________________ costs for services rendered associated with filing my petition.

I do not have the ability to pay the costs for services rendered associated with filing my petition and have completed the defendant's statement of assets.

(CR-115)

I declare under the penalty of perjury under the laws of the state of California that the foregoing is true and correct.

Date Signature of Declarant

CRIM 132 (Declaration Re: Costs) ATTACHMENT #2

(PC § 987.8(g)(2))

People of the State of California

Notice Regarding Ability To Reimburse Cost Of Services Rendered PC§§ 1203.4(d), 1203.4a(e) and 1203.41(d)

Reserved for Clerk's File Stamp

CASE NUMBER:

SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES

CRIM 243 (Rev. 03/16)

Notice Regarding Ability To Reimburse Cost of Services RenderedPC§§ 1203.4(d), 1203.4a(e) and 1203.41

(Plaintiff / Respondent)

vs.

(Defendant / Petitioner)(First Name, Last Name)

The court finds the defendant/petitioner:

does not have the ability to reimburse the court for the actual cost of services rendered. does have the ability to reimburse the court for the actual cost of services rendered in the amount of $_________. Payment is due immediately upon receipt of this notice.

The defendant/petitioner:

Has not remitted any payment associated with this Petition for Dismissal.

Remitted payment on __________(date) in the sum of $_________.

has a remaining balance of $_______due payable to the court, associated with the

actual cost of services rendered. Payment is due immediately upon receipt of this notice.

will receive a refund of $________ via USPS to the address identified on the Petition for Dismissal.

Other: _________________________________________________________________________

SHERRI CARTER, Executive Officer/Clerk

BY: ______________________________Deputy Clerk

If you are getting public benefits, are a low-income person, or do not have enough income to pay for your household’s basic needs and your court fees, you may use this form to ask the court to waive your court fees. The court may order you to answer questions about your finances. If the court waives the fees, you may still have to pay later if:

• You cannot give the court proof of your eligibility,• Your financial situation improves during this case, or• You settle your civil case for $10,000 or more. The trial court that waives

your fees will have a lien on any such settlement in the amount of thewaived fees and costs. The court may also charge you any collection costs.Your Information (person asking the court to waive the fees):Name:Street or mailing address:

State: Zip:City:Phone number:Your Job, if you have one (job title):

Employer’s address:

The lawyer has agreed to advance all or a portion of your fees or costs (check one):(If yes, your lawyer must sign here) Lawyer’s signature:

Why are you asking the court to waive your court fees?

b.

Name of employer:

If your lawyer is not providing legal-aid type services based on your low income, you may have to go to a hearing to explain why you are asking the court to waive the fees.

Your Lawyer, if you have one (name, firm or affiliation, address, phone number, and State Bar number):

What court’s fees or costs are you asking to be waived?

I declare under penalty of perjury under the laws of the State of California that the information I have provided on this form and all attachments is true and correct.

a. b.

Yes No

Superior Court (See Information Sheet on Waiver of Superior Court Fees and Costs (form FW-001-INFO).)Supreme Court, Court of Appeal, or Appellate Division of Superior Court (See Information Sheet on Waiver of Appellate Court Fees (form APP-015/FW-015-INFO).)

My gross monthly household income (before deductions for taxes) is less than the amount listed below. (Ifyou check 5b, you must fill out 7, 8, and 9 on page 2 of this form.)

Check here if you asked the court to waive your court fees for this case in the last six months.(If your previous request is reasonably available, please attach it to this form and check here:)

a. I receive (check all that apply; see form FW-001-INFO for definitions):Medi-Cal

Food StampsSSP

Supp. Sec. Inc.County Relief/Gen. Assist. IHSS CalWORKS or Tribal TANF CAPI

c. I do not have enough income to pay for my household’s basic needs and the court fees. I ask the court to:(check one and you must fill out page 2):

let me make payments over time waive all court fees and costs

Family Size Family Income Family Size Family Income Family Size Family Income1 $1,256.26 3 $2,127.09 5 $2,997.922 $1,691.67 4 $2,562.51 6 $3,433.34

If more than 6 people at home, add $435.42 for each extra person.

Judicial Council of California, www.courts.ca.gov Revised March 1, 2017, Mandatory Form Government Code, § 68633 Cal. Rules of Court, rules 3.51, 8.26, and 8.818

Request to Waive Court Fees FW-001, Page 1 of 2

Sign herePrint your name here

Date:

1

2

3

4

5

Clerk stamps date here when form is filed.

Fill in court name and street address:

Superior Court of California, County of

Fill in case number and name:

Case Number:

Case Name:

CONFIDENTIAL

6

FW-001 Request to Waive Court Fees

waive some of the court fees

If you checked 5a on page 1, do not fill out below. If you checked 5b, fill out questions 7, 8, and 9 only. If you checked 5c, you must fill out this entire page. If you need more space, attach form MC-025 or attach a sheet of paper and write Financial Information and your name and case number at the top.

Your Money and PropertyCashAll financial accounts (List bank name and amount):(1) $Your Gross Monthly Income(2) $

List any payroll deductions and the monthly amount below:

(3) $

$(1)(2) $

Cars, boats, and other vehiclesc.

$(3)

Fair Market Value

How Much You Still Owe

(4) $

Make / Year(1) $ $(2) $ $

List the source and amount of any income you get each month, including: wages or other income from work before deductions, spousal/child support, retirement, social security, disability, unemployment, military basic allowance for quarters (BAQ), veterans payments, dividends, interest, trust income, annuities, net business or rental income, reimbursement for job-related expenses, gambling or lottery winnings, etc.

a.

Real estated. Fair Market Value

How Much You Still OweAddress

(1) $ $(2) $ $

(1) $

e. Other personal property (jewelry, furniture, furs,stocks, bonds, etc.):

(2) $(3) $(4) $

Describe(1) $ $

Your total monthly income:b. $

(2) $ $

$ $(3)

Household Income

Your Monthly Deductions and Expenses

List the income of all other persons living in your home who depend in whole or in part on you for support, or on whom you depend in whole or in part for support.

Gross Monthly Income

b. Rent or house payment & maintenance $

RelationshipName

c. $

(1) $

d. $

(2) $

e. Clothing $

(3) $

f. Laundry and cleaning $

(4) $

g. $$

b. Total monthly income of persons above:

i. School, child care $

$

Child, spousal support (another marriage)j.

Total monthly income and household income (8b plus 9b):

Transportation, gas, auto repair and insurancek.

$

l. Installment payments (list each below):Paid to:

(1) $

(2) $(3)

Wages/earnings withheld by court orderAny other monthly expenses (list each below).

Paid to: How Much?(1) $

Important! If your financial situation or ability to pay court fees improves, you must notify the court within five days on form FW-010.

(2) $(3) $

Total monthly expenses (add 11a –11n above): $

If it does, complete the form based on your average income for the past 12 months.

a.

h.

$

$

Fair Market Value

How Much You Still Owe

$$

a.

Age

b.

m.n.

Food and household suppliesUtilities and telephone

Medical and dental expensesInsurance (life, health, accident, etc.)

$

Check here if your income changes a lot from month to month.

Case Number:

Your name:

Revised March 1, 2016 Request to Waive Court Fees FW-001, Page 2 of 2

7

8

9

10

11

To list any other facts you want the court to know, such as unusual medical expenses, etc., attach form MC-025 or attach a sheet of paper and write Financial Information and your name and case number at the top.

Check here if you attach another page.

$

a.


A request to waive court fees was filed on (date):

Read this form carefully. All checked boxes are court orders.þ

(1) Fee Waiver. The court grants your request and waives your court fees and costs listed below. (Cal. Rules of Court, rules 3.55 and 8.818.) You do not have to pay the court fees for the following:

• Giving notice and certificates• Sending papers to another court department• Court-appointed interpreter in small claims court

• Reporter’s fee for attendance at hearing or trial, if reporter provided by the court• Assessment for court investigations under Probate Code section 1513, 1826, or 1851• Preparing, certifying, copying, and sending the clerk’s transcript on appeal• Holding in trust the deposit for a reporter's transcript on appeal under rule 8.130 or 8.834• Making a transcript or copy of an official electronic recording under rule 8.835

(2) Additional Fee Waiver. The court grants your request and waives your additional superior court fees and costs that are checked below. (Cal. Rules of Court, rule 3.56.) You do not have to pay for the checked items.

Jury fees and expenses Fees for a peace officer to testify in court Court-appointed interpreter fees for a witness Fees for court-appointed experts

Order on Court Fee Waiver (Superior Court) FW-003, Page 1 of 2Judicial Council of California, www.courts.ca.gov Revised July 1, 2015, Mandatory Form Government Code, § 68634(e) Cal. Rules of Court, rule 3.52

• Filing papers in Superior Court• Making copies and certifying copies• Sheriff ’s fee to give notice• Court fee for phone hearing

Person who asked the court to waive court fees:

Notice: The court may order you to answer questions about your finances and later order you to pay back the waived fees. If this happens and you do not pay, the court can make you pay the fees and also charge you collection fees. If there is a change in your financial circumstances during this case that increases your ability to pay fees and costs, you must notify the trial court within five days. (Use form FW-010.) If you win your case, the trial court may order the other side to pay the fees. If you settle your civil case for $10,000 or more, the trial court will have a lien on the settlement in the amount of the waived fees. The trial court may not dismiss the case until the lien is paid.

a. The court grants your request, as follows:

Name:Street or mailing address:City: State: Zip:

The court made a previous fee waiver order in this case on (date):

FW-003 Order on Court Fee Waiver(Superior Court)

Clerk stamps date here when form is filed.

Fill in court name and street address:Superior Court of California, County of

Fill in case number and name:

Case Number:

Case Name:

Request to Waive Court Fees Request to Waive Additional Court FeesAfter reviewing your:the court makes the following orders:

Lawyer, if person in has one (name, address, phone number, e-mail, and State Bar number):

1

2

3

4

1

(specify): Other

(1) The court denies your request because it is incomplete. You have 10 days after the clerk gives notice of this order (see date of service on next page) to:

Pay your fees and costs, or

(2)

Pay your fees and costs in full or the amount listed in c. below, or Ask for a hearing in order to show the court more information. (Use form FW-006 to request hearing.)

The court needs more information to decide whether to grant your request. You must go to court on the date below. The hearing will be about (specify questions regarding eligibility):

c.

Bring the following proof to support your request if reasonably available:

Warning! If item c is checked, and you do not go to court on your hearing date, the judge will deny your request to waive court fees, and you will have 10 days to pay your fees. If you miss that deadline, the court cannot process the court papers you filed with your request. If the papers were a notice of appeal, the appeal may be dismissed.

Date: Signature of (check one):

Order on Court Fee Waiver (Superior Court) FW-003, Page 2 of 2Revised July 1, 2015

•

••

b. The court denies your fee waiver request, as follows:

•

Warning! If you miss the deadline below, the court cannot process your request for hearing or the court papers you filed with your original request. If the papers were a notice of appeal, the appeal may be dismissed.

File a new revised request that includes the items listed below (specify incomplete items):

Judicial Officer Clerk, Deputy

The court denies your request because the information you provided on the request shows that you are not eligible for the fee waiver you requested (specify reasons):

Your name:Case Number:

Date: Time:Room:Dept.:

Hearing Date

g

Name and address of court if different from above:

This is a Court Order.

The court has enclosed a blank Request for Hearing About Court Fee Waiver Order (Superior Court), form FW-006.You have 10 days after the clerk gives notice of this order (see date of service below) to:

Request for Accommodations. Assistive listening systems, computer-assisted real-time captioning, or sign language interpreter services are available if you ask at least 5 days before your hearing. Contact the clerk’s office for Request for Accommodation, Form MC-410. (Civil Code, § 54.8.)

I certify that I am not involved in this case and (check one):Clerk's Certificate of Service

This order was mailed first class, postage paid, to the party and attorney, if any, at the addresses listed in and , from

Date:, California on the date below.

Clerk, by , Deputy

A certificate of mailing is attached.I handed a copy of this order to the party and attorney, if any, listed in and , at the court, on the date below.1 2

(city):1 2


CR-115FOR COURT USE ONLYNAME OF VICTIM ON WHOSE BEHALF RESTITUTION IS ORDERED:

NAME OF COURT:

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

PEOPLE OF THE STATE OF CALIFORNIAvs.

DEFENDANT:CASE NUMBER:DEFENDANT'S STATEMENT OF ASSETS

It is a misdemeanor to make any willful misstatement of material fact in completing this form (Pen. Code, § 1202.4(f)(4).)

(Attach additional sheets if the space provided below for any item is not sufficient.)PERSONAL INFORMATION

EMPLOYMENT2. What are your sources of income and occupation? (Provide job title and name of division or office in which you work.)

3. a. Name and address of your business or employer (include address of your payroll or human resources department, if different):

b. If not employed, names and addresses of all sources of income (specify):

4. How often are you paid (for example, daily, weekly, biweekly, monthly)? (specify):5. What is your gross pay each pay period? $6. What is your take-home pay each pay period? $7. If your spouse earns any income, give the name of your spouse, the name and address of the business or employer, job title, and

division or office (specify):

8. Other sources of income (specify):

CASH, BANK DEPOSITS9. How much money do you have in cash? $10. How much other money do you have in banks, savings and loans, credit unions, and other financial institutions either in your own

name or jointly (list):Name and address of financial institution Individual or joint?Account number Balance

a. $

b. $

c. $

PROPERTY11. List all automobiles, other vehicles, and boats owned in your name or jointly. Legal owner if different

from registered ownerAmountOwed Make and year Value

a.b.c.

(Continued on reverse)

DEFENDANT'S STATEMENT OF ASSETSAdopted for Mandatory Use Judicial Council of California CR-115 [Rev. July 1, 2013]

Penal Code, § 1202.4(f)

$$$

$$$

1. a. Name:b. AKA:c. Date of birth:d. Social security number:e. Marital status:

f. Driver license number. State of issuance:g. Home address (incl. city/zip):

h. Home telephone no.:i. Employer's telephone no.:

PEOPLE OF THE STATE OF CALIFORNIA vs. DEFENDANT:

CASE NUMBER:

12. List all real estate owned in your name or jointly:Fair market value Amount owed

a. $ $

$b. $

OTHER PERSONAL PROPERTY (Do not list household furniture and furnishings, appliances, or clothing.)13. List anything of value not listed above owned in your name or jointly (continue on attached sheet if necessary):

Description Value Address where property is locateda.b.c.

ASSETS14. List all other assets, including stocks, bonds, mutual funds, and other securities (specify):

Yes.15. Is anyone holding assets for you? No. If yes, describe the assets and give the name and address of theperson or entity holding each asset (specify):

16. Except for attorney fees in this matter and ordinary and routine household expenses, have you disposed of or transferred anyassets since your arrest on this matter? Yes. No.If yes, give the name and address of each person or entity who received any asset and describe each asset (specify):

DEBTS

21.1. Other debts (specify):

Date:

(TYPE OR PRINT NAME) (SIGNATURE)

, a certified interpreter, having been duly sworn, truly translated this form to the defendant language. The defendant indicated that he/she understood the contents of

I, (name):in the (specify language):the form and he/she completed the form.Date:

(SIGNATURE)(TYPE OR PRINT NAME)

DEFENDANT'S STATEMENT OF ASSETSCR-115 [Rev. July 1, 2013] Page two

$

$$

Address of real estate

17. Loans (give details):

18. Taxes (give details):

19. Support arrearages (attach copies of orders and statements):

20. Credit cards (give creditor's name and address and the account number):

POS-030ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

CASE NUMBER:

PROOF OF SERVICE BY FIRST-CLASS MAIL—CIVIL

I am over 18 years of age and not a party to this action. I am a resident of or employed in the county where the mailing took place.

My residence or business address is:

On (date): I mailed from (city and state): the following documents (specify):

I served the documents by enclosing them in an envelope and (check one):a. depositing the sealed envelope with the United States Postal Service with the postage fully prepaid. b.

The envelope was addressed and mailed as follows:Name of person served:


Date:

(TYPE OR PRINT NAME OF PERSON COMPLETING THIS FORM) (SIGNATURE OF PERSON COMPLETING THIS FORM)

Form Approved for Optional Use Judicial Council of California POS-030 [New January 1, 2005]

PROOF OF SERVICE BY FIRST-CLASS MAIL—CIVIL Code of Civil Procedure, §§ 1013, 1013a

1.

2.

3.

placing the envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business’s practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service in a sealed envelope with postage fully prepaid.

4.

Address of person served:b.a.

www.courtinfo.ca.gov

PETITIONER/PLAINTIFF:

RESPONDENT/DEFENDANT:

TELEPHONE NO.:

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OFSTREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

FAX NO. (Optional):

(Do not use this Proof of Service to show service of a Summons and Complaint.)

The name and address of each person to whom I mailed the documents is listed in the Attachment to Proof of Service by First-Class Mail—Civil (Persons Served) (POS-030(P)).

The documents are listed in the Attachment to Proof of Service by First-Class Mail—Civil (Documents Served) (form POS-030(D)).

5.

E-MAIL ADDRESS (Optional):

(Proof of Service)