CITY OF LOS ANGELES DEPARTMENT OF TRANSPORTATION

CITY OF LOS ANGELES

DEPARTMENT OF TRANSPORTATION

PARKING VIOLATIONS BUREAU

INFORMATION SHEET ON INSTALLMENT PAYMENT PLAN FOR PARKING CITATIONS

The City of Los Angeles allows individuals to request an Installment Payment Plan only in cases where the individuals can document

that they meet the criteria as a very-low-income household (3 options with qualifying criteria – see below). If your installment

payment plan request is denied, the total amount due must be paid in full.

Option #1. If you are claiming eligibility for a payment plan because you receive financial assistance under one or more of these

programs, you must produce official documentation confirming benefits from a public assistance agency and/or one of the following

documents, PLUS you must fill out an Installment Payment Plan Form – household income and expenditures:

PROGRAM

VERIFICATION DOCUMENTATION REQUIRED

SSI/SSP

Medi-Cal Card or Notice of Planned Action or SSI Computer – generated

Printout or Bank Statement(s) showing SSI deposits (3 months)

Cal WORKS/TANF

Medi-Cal Card or Notice of Action or Income & Eligibility Verification

Form or Monthly Reporting Form or Electronic Benefit Transfer Card

FOOD STAMPS PROGRAM

Notice of Action or Food Stamp ID Card

General Relief/General Assistance

Notice of Action or Copy of Check Stub or County Voucher

Option #2. Total gross annual household income is equal to or less than the following:

NUMBER IN FAMILY

FAMILY GROSS ANNUAL INCOME:

(Support documentation required)

1 person

$30,400

2 people

$34,750

3 people

$39,100

4 people

$43,400

5 people

$46,900

6 people

$50,350

7 people

$53,850

8 people

$57,300

Option #3. Your income is not enough to pay for the common necessities of life for yourself and the people you support and also pay

for parking fines. Financial records (i.e., W-2 forms, Social Security payments, unemployment checks, bank statements, alimony

payments, etc.) are required. List of all monthly expenditures with supporting documentation is required.

To apply for an Installment Payment Plan, fill out the attached application and submit the completed form with all required

supporting documentation for all entries. Failure to provide supporting documentation will result in your request being

automatically denied and you will not have an opportunity to submit additional information. ALL approval or denial of

Installment Payment Plan applications will be in writing and mailed to the contestant. The decision rendered is final and cannot

be disputed.

CITY OF LOS ANGELES

APPLICATION FOR AN INSTALLMENT PAYMENT PLAN

Mail To: Parking Violations Bureau, PO Box 30420, Los Angeles, CA 90030

Name:

Address:

City, State, and Zip Code:

Telephone numbers:

CITATION(S) #

AMOUNT OF FINE

DUE DATE

Under penalty of perjury, I certify that all statements made are accurate. I have read the “Installment Payment Plan Request” and

understand this application is subject to approval and review based on the criteria established.

Note: If your application for an Installment Payment Plan is denied, all fines must be paid. If you are approved for and enrolled in a

plan, you are forfeiting your right to contest these citations.

Signature and Date required: ____________________________________________________________________________

****************************************************************************************************

In order to qualify for an Installment Payment Plan, please check each item that applies to you. You will be required to submit

supporting documentation for each entry; failure to do so will result in an automatic denial of your request. You may mail this

completed form with supporting documentation to: Parking Violations Bureau, PO Box 30420, Los Angeles, CA 90030.

☐ I am receiving financial assistance under one or more of the following. I must provide supporting documentation (refer to

Information Sheet on Fee Waivers) for each entry:

☐SSI and SSP* ☐Cal Works*

☐Food Stamps Program* ☐General Relief/General Assistance*

* Supporting documentation is required; without support documentation your application will be denied.

* If you checked this box, you must complete the Financial Information Worksheet on the back and submit

supporting documentation for each entry.

☐ My total gross annual household income is less than the amount shown on the Information Sheet. (If you checked this box, you

must complete the Financial Information Worksheet on the back and submit documentation for each entry).

Number in Family: Annual Gross (before deductions) Household Income:

☐ My income is not enough to pay for common necessities of life and the people in my family whom I support and also pay citation

fines. (If you check this box, you must complete the Financial Information Worksheet on the back and submit supporting

documentation for each entry).

Your Name: ___________________________________________________ Vehicle License Plate: _____________________

If you checked 1, 2, or 3 on the front page, you must complete this form and provide supporting documentation for entries (supporting

documentation must be official documents, not handwritten notes). If this record is incomplete, your request will be denied.

Supporting documents will not be returned.

Household Monthly Income:

a. Gross monthly income (before deductions)

$_______________________

b. Total monthly deductions (payroll)

$_______________________

c. Total monthly take home pay

$_______________________

d. *List the source and amount of ANY other income

you get each month, including: spousal/child support,

retirement, social security, disability, unemployment,

military basic allowance for quarters (BAQ),

veteran’s payments, dividends, interest, trust income,

annuities, net business or rental income, tuition

reimbursement, job related reimbursement, gambling

or lottery winnings, parental support (see * note

below), etc.

1:___________________ $____________

2:___________________ $____________

3:___________________ $____________

Total Monthly Income is $__________________

(ADD c plus d)

Please submit official documentation to support each entry,

for example, official social security benefits letters, official

tuition and grant statements, rental/property income (tax

forms), etc.

Your Money and Property (assets)

a-Cash $__________

b-All financial accounts (including all savings,

checking, CDs, Money Market, etc. List bank name

and amount)

1.______________________ $__________

2.______________________ $__________

3.______________________ $__________

c-Credit cards (s) amount owed:

Name (Visa, MasterCard, Discover, AMEX, etc.)

1:______________________________________

Amount owed:

$ ______________________________________

2:______________________________________

$ ______________________________________

3:______________________________________

$ ______________________________________

4:______________________________________

$ ______________________________________

d-Cars, boats, and other vehicles:

Make/Yr: Amount Owed:

1:____________________$________________

2:_____________________$_______________

3:_____________________$_______________

4:_____________________$_______________

Household Monthly Expenses:

1. Rent or Mortgage* $__________________

2. Food (monthly est.) $__________________

3. Utilities* (tel., electric, etc.) $__________________

4. Clothing (est.) $__________________

5. Laundry/Cleaning* $__________________

6. Medical/Dental bills* $__________________

7. Insurance bills* $__________________

8. School/Childcare* $__________________

9. Child/spousal support* $__________________

10. Transportation/gas $__________________

11. Loans*_______________________________________

12. Misc.*_______________________________________

TOTAL EXPENSES: (add 1-12) $__________________