Revised 10/31/2025 Form #: L-776 Optional CANNOT AFFORD TO PAY FINE: TRAFFIC AND OTHER INFRACTIONS Page 1 of 4 SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE Central - 700 Civic Center Dr. West, Santa Ana, CA 92701 - 4045 Harbor - 4601 Jamboree Rd., Newport Beach, CA 92660 North - 1275 N.

Berkeley Ave., Fullerton, CA 92838 West - 8141 13th Street, Westminster, CA 92683 Court Use Only CANNOT AFFORD TO PAY FINE: TRAFFIC OR OTHER INFRACTIONS (CONFIDENTIAL) Citation/Case Number: OC Pay Number: Using this form: • If you cannot afford to pay your fine, fill out this form to request a fine reduction, payment plan, more time to pay, and/or community service. • Use this form for traffic fines or other infractions. • You may use this form if your fine has been sent to collections. • If you have more than one citation, use a separate form for each citation. • Mail or take this form to the court listed on your ticket.

Important! Do not use this form to tell the court that you didn’t do anything wrong. See the instructions on your ticket and visit www.occourts.org/directory/traffic/general-information/fees.html.  Your Information Name: Social Security Number: Street/Mailing Address: Select ‘Yes’ if you authorize the court to send automated call reminders. Message & Data Rates may apply. Email (optional): OK to send notices to this email?

Yes No Select 'Yes' if you authorize the court to send electronic notices.  Plea selection: (In order to submit your request using this form, if your case is unadjudicated, you need to admit responsibility for the ticket by entering a plea of guilty or no contest. If you do not want to admit responsibility or you do not understand your rights, do not use this form. Instead, contact the court to

schedule a court appearance.) By entering a plea you will be giving up the following rights: • To be represented by an attorney employed by you; • To have a speedy and public trial in front of a judge; • To testify, to present evidence, and to use court orders without cost to compel the attendance of witnesses and the production of evidence on your behalf; • To have the witnesses against you testify under oath in court, and to question such witnesses • To remain silent and not testify and not incriminate yourself; Street City State Zip Telephone: OK to use this number for court reminders?

Yes No CONFIDENTIAL Revised 10/31/2025 Form #: L-776 Optional CANNOT AFFORD TO PAY FINE: TRAFFIC AND OTHER INFRACTIONS Page 2 of 4 Citation/Case Number: (Plea selection continued) Make a choice between pleading guilty or no contest. A no contest plea is a way of saying, “I don't believe I did all that the officer charges, but I admit violating the law.” Note: Once you admit responsibility, you will have a conviction for this traffic offense that will be reported to the Department of Motor Vehicles (DMV). Your plea (Check one): No contest plea. I am the defendant in the case.

I have read, understand, and waive the rights above; there are facts to support my plea; I am entering my plea freely and voluntarily, and I agree to plead "no contest." I understand that, for purposes of this case, a plea of no contest will be considered the same as a plea of guilty and that if l plead no contest the court will find me guilty. Guilty plea. I am the defendant in the case. I have read, understand, and waive the rights above, there are facts to support my plea. I am entering my plea freely and voluntarily, and agree to plead guilty.  What type of income do you have?

I do not receive money from any source. (Skip to Step 4 ) I receive public benefits. (Check all that apply, then skip to Step 4) For example: Food stamps (CalFresh) State Supplementary Payment (SSP) Medi-Cal County Relief/General Assistance CalWORKs or Tribal TANF In-Home Supportive Services (IHSS) Supplemental Security Income (SSI) Cash Assistance Program for Immigrants (CAPI) Unemployment compensation WIC: California Special Supplemental Nutrition Other need-based aid (specify): I do not receive public benefits, but I receive money from other sources. (Answer all that apply) a.

How much money do you earn (take-home pay) or receive from other sources (including income received in your family from a spouse or domestic partner)? $ every: (Check one) Year Every Other Week Week Month Other b. This money supports me and other people. c. If I pay the fine, I would: (Check all that apply, if any) not have enough money to pay my rent/mortgage. I pay $ for rent/mortgage every: (Check one): Month Week Other: not have enough money to pay for other basic living expenses.

Basic living expenses are things like: food, utilities, childcare, child support, transportation, medication, insurance (medical, car, house, and rental), and student loans. not have enough money to pay my debt for other court cases.

List other court cases: have other problems. (Please explain): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ CONFIDENTIAL Revised 10/31/2025 Form #: L-776 Optional CANNOT AFFORD TO PAY FINE: TRAFFIC AND OTHER INFRACTIONS Page 3 of 4 Citation/Case Number: Do you have anything that shows your public benefits, income or expenses? Things like an EBT card, paystubs, tax returns, rent or mortgage checks, or utility bills. a.

Yes, I have attached copies of supporting documents. Important! Only send copies (be sure to cross out any confidential information), keep the original documents for your own records. Any copies you attach can be destroyed after the court makes a decision on your case. b. No, I do not have any papers to show because:  Have you already told the court before that you cannot pay this fine?

Yes No (Skip to Step 5) What circumstances have changed? (Check all that apply, if any) Lost job or reduced hours at work Started to receive public benefits Suffered a serious illness or disability Other:  What are you asking the court to do? (Check all that apply) Lower the amount I owe on the fine. Payment plan: I want to pay the total fine as: $ every month on the is paid off. day of the month, until this fine More time to pay: Please change my deadline to (month/date/year): Community service instead of paying the fine.

I understand that community service may not be available on weekends or evenings and other fees will apply. I declare that I have no physical limitations that may prevent my acceptance into the program. Cancel or lower my civil assessment that was previously imposed for failing to appear on time. CONFIDENTIAL Some fines cannot be reduced just because you don't have the money to pay. You may ask for more time to pay, community service, and/or monthly payments even if the court cannot reduce the fine.

Revised 10/31/2025 Form #: L-776 Optional CANNOT AFFORD TO PAY FINE: TRAFFIC AND OTHER INFRACTIONS Page 4 of 4 Citation/Case Number:  Other information: List other facts (if any) about why you cannot pay the fine or about your choices in Step 5, (attach other documents that help you explain).  Traffic School: I am the defendant in the case and I request traffic school.  Read and sign below I promise that the information above is correct. “I declare under penalty of perjury, under the laws of the State of California, that all information on or attached to this form is true.

Perjury is a felony in California and is punishable by imprisonment in the county jail for two, three, or four years. (Penal Code § 126).” Date:  Type or print your name Sign your name CONFIDENTIAL