Contesting a Citation - Example E
Sample Declaration of Financial Hardship

DECLARATION OF FINANCIAL HARDSHIP

Citation NO: _______________________   AMT DUE ___________________________________

BAIL AGREEMENT: I hereby state that I am unable to post the required penalty far the hearing deposit at this time. If I am found guilty, I understand that I will be required to pay the penalty due or s et-up a payment schedule within (20) days of the mailing of the results of the Administrative Review Hearing. If I fail to resolve this matter, I further understand that one or more of the following could take place:

1. My vehicle may be impounded
2. A Lien may be placed against California Tax Return
3. The penalty may be increased and a lien may be placed against my vehicle registration.
4. The claim may be assigned to a collection agency

NAME & ADDRESS :
______________________________________
______________________________________
______________________________________
______________________________________

DRIVER'S LIC # -: ________________________

SOCIAL SEC #: _________________________

EMPLOYER NAME & ADDRESS
______________________________________
______________________________________
______________________________________
______________________________________

NET MONTHLY INCOME__________________

(Take-home pay, Welfare, etc)

I DECLARE under penalty of perjury that the foregoing Is true and correct

SIGNATURE __________________________________ DATE ___________________