Declaration of Inability to Pay Waiver

Los Angeles Metro Protective Services
Los Angeles County Sheriff’s Department
PO Box 866015
Los Angeles, CA 90086-6015
213.92COURT (213.922.6878)
metro.net/transitcourt
DECLARATION OF INABILITY TO PAY WAIVER
REQUEST FOR WAIVER OF POSTING OF PENALTIES FOR ADMINISTRATIVE HEARING
INSTRUCTIONS: Please include this form and copies of documentation supporting the income level claimed below when submitting the
Administrative Hearing Request Form to the address noted above. Acceptable documentation includes but is not limited to, any
documentation stating your eligibility for public assistance, SSI, SSP, unemployment or other income source, your most recent tax return,
W2 or one month’s current pay stub. Failure to provide adequate documentation may result in denial of payment waiver.
A payment waiver is not used to grant exemptions from payment of violation fees on the grounds of financial hardship, nor is there any
provision in current state law which permits a reduction in fines. The financial disclosure statement is used only to waive the prepayment of
violation fees required for scheduling an administrative hearing, during which you may challenge the legitimacy of the violation.
1.
I am unable to pay the fine amount because:______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________
2.
EMPLOYMENT
HOUSEHOLD INCOME (monthly)
FINANCIALLY RESPONSIBLE FOR:
Check one
Check all that apply
Check all that apply
 Employed full time
 Self $_______
 Self $_______
 Employed part time
 Spouse $_______
 Spouse $_______
 Unemployed
 Public assistance $_______
 Children how many? ____ $_______
 Disabled
 SSI&SSP $_______
 Other _______ $_______
 Student
 Unemployment $_______
(B) Total $ _____________
 Homemaker
 Other _______ $_______
Your net monthly income:
 Military
(A) Total $ _____________
(A) – (B) = $ ____________
 Other _______
Name of current/most recent employer: _______________________________
If unemployed, months of employment: ________
ASSETS (VALUE)
MONTHLY EXPENSES
 Motor Vehicles $_______
 Rent/Mortgage
 Home $_______
 Utilities $_______
 Property $_______
 Loans/credit cards $_______
 Savings $_______
 Food/clothing $_______
 Checking $_______
 Transportation $_______
 Cash on Hand $_______
 Medical/Dental $_______
 All other ______ $_______
 Telephone $_______
Total Assets $ __________
 Cell Phone $_______
$_______
 All other _______ $_______
Total Expenses $ __________
3. I am entering the following plea:  Liable  Not Liable
4. I am interested in the following options as I am experiencing financial difficulty:
 Transit School - 20-minute online tutorial which will result in a reduction of fines
 Installment Payment Plan - payment of fines over a period of three months
 Community Service - volunteer work hours in lieu of payment of fines
5. I state and declare, under the penalty of perjury, that the foregoing is true and correct.
Name: __________________________
Signature: ________________________________________ Date: ____________