Contesting a Citation - Example H
Sample Payment Schedule Form

PAYMENT SCHEDULE 

CITATION NO. ___________   AMOUNT DUE_______________

NAME ____________________   NET MONTHLY INCOME:___________
          (Take Home pay/welfare, etc)

Employer: __________________________   Social Security No: _____________________

Employer Address ________________________________________________________
Street Address ___________________________________________________________

I hereby state that I am unable to pay the required penalty in full at this time and promise to make the payments as follows:

  1. _____ due _____  2. _____ due _____ 3. _____ due _____ 
  4. _____ due _____  5. _____ due _____ 6. _____ due _____

I understand that failure to make the above payments will result in this payment schedule being cancelled and one or all of the following actions:

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

It is the responsibility of the party signing this agreement to make the monthly payments on the due date. NO REMINDERS WILL BE SENT.

I declare under penalty of perjury that the foregoing is true and correct:

Signature: ____________________   Date: ________________