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Administrative Citation Request for Advance Deposit Hardship Waiver Form

2. If you are financially unable to make an advance deposit of the fine amount and/or appeal fee prior to an appeal hearing, you may request an advance deposit hardship waiver. The request must be submitted within 15 days of the date of service of the administrative citation. Please see guidelines below.

4. To be eligible for an Advance Deposit Hardship Waiver, you must meet the U.S. Department of Housing and Urban Development (HUD) established income limits for the Very Low or 50% of Area Median Income for Santa Clara County.

6. 

8. The information you provide will assist the City in deciding whether you qualify for a waiver of advance deposit for your hearing request. The advance deposit hardship waiver program is voluntary. If you choose to apply, you must provide the information requested. Failure to provide sufficient information will result in a determination of ineligibility for this waiver.

12. Citation issued to:*

13. Phone Number*

15. Citation Number(s):*

16. Citation Date(s):*

18. Violation Address*

20. Name of Requestor: *

21. Phone Number*

23. I received the above noted citation(s) and hereby request an advance deposit hardship waiver. I declare that I am financially unable to make the advance deposit.

    I received the above noted citation(s) and hereby request an advance deposit hardship waiver. I declare that I am financially unable to make the advance deposit.

25. My family's gross income is received:*
    -- Select One --weeklybi-weeklymonthlyannual

26. Gross income received:*

27. Family size including yourself:*

29. Proof of Income Documentation*

    Current proof of income is required. You must include documentation of ALL household income for the requestor. Please provide verification copies of all that apply: • Federal Income Tax Return (Form 1040, 1040A) for the previous year • Current Letter 1722 from the IRS for non-income adults (1-800-829-1040) • Current verification of Social Security Benefits (1-800-772-1213) • Current Welfare of General Assistance eligibility Notice of Action/Income Verification • Current Documentation of Unemployment from Employment Development Department (1-800- 300-5616

31. Acknowledgement*

    By typing your name above you declare under penalty and perjury that you are the cited individual and the foregoing statement and information provided are true and correct.

32. Date*

34. Contact Information
    City of Morgan Hill Finance Department (408) 779-7237; 17575 Peak Avenue Morgan Hill, CA 95037

    City of Morgan Hill Finance Department (408) 779-7237; 17575 Peak Avenue Morgan Hill, CA 95037

38. For Finance Director (or his/her designee) Use Only

40. Deposit Waiver

    1. Granted

    1. Declined

41. Signature

42. Date

44. Reason(s) for decision:

46. Date requestor was informed

47. Initials

49. Date forwarded to appeal hearing officer

50. Initials

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field