s) checked below constitute good cause for my failure to appear and support(

s) my request to vacate the civil assessment: (You must complete this

section and you must attach written proof that the reason(

s) existed on the appearance due date.) Hospitalization Out-of-state military duty Incarceration Other (explain):_________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the statements above are true and correct to the best of my knowledge and that written proof is attached to this form.

Executed on at ___ (Date) (City and State) Signed: ________________________________________________ ORDER (COURT USE ONLY) The Court, having read and considered the foregoing, orders the Application to Vacate: Denied Reason for denial (optional): ____________________________________________ ____________________________________________________________________ ____________________________________________________________________ Your case has been referred to Linebarger Goggan Blair & Sampson, LLP for collection. Please contact Linebarger within 10 days to make payment in full or to arrange monthly payments.

MAILING ADDRESS Telephone: 1-844-544-5358 PO Box Online Payments: https://www.lgbswebpayments.com San Antonio, TX Granted Date: Judge of the Superior Court APPLICATION AND ORDER TO VACATE CIVIL ASSESSMENT (rev. 06-27-19)