CLERK’S NOTICE OF FINES AND COSTS Case No.

COMMONWEALTH OF VIRIGNIA Va. Code §§ 19.2-354, 19.2-358, 46.2-395

, Circuit Court

DEFENDANT:

You are responsible for the following fines, costs, forfeitures, restitution, and/or penalties. Interest begins to accrue forty (40) days after the due date. ALL FINES, COSTS, FORFEITURES, RESTITUTION, AND/OR PENALTIES ARE DUE ON DATE OF JUDGMENT UNLESS DELAY IS GRANTED.

If you fail to pay the following fines, costs, forfeitures, restitution, and/or penalties by the date of judgment, or if you are allowed to make installment payments or a deferred payment with the consent of the Court, and fail to make such scheduled payment(s), the Clerk is required to report such failure to the Court, the Department of Motor Vehicles, the Department of Taxation, the State Compensation Board and the Attorney for the Commonwealth. In addition, a capias may be issued for your arrest and you may be subject to any one or more of the following:

1. the Court may impose additional fines and/or imprisonment;

2. the Court may revoke part or all of any suspended sentence;

3. your fines, costs, forfeitures, restitution and/or penalties will be offset against any tax refund, lottery winnings or other funds due you from the Commonwealth;

4. your driver’s license will be automatically suspended effective ten days from date of conviction or immediately after the due date of a missed payment or ten days following notice that a check or credit card payment has been dishonored by the bank or issuing institution;

5. DMV will revoke your automobile registration certificate and plates and/or refuse to issue new registration or plates until fines, costs, forfeitures, restitution and/or penalties are paid;

6. collection procedures will be undertaken to subject your property to the payment of the costs, fines, forfeitures, restitution and/or penalties due;

7. the Court will revoke any privileges you may have to serve all or part of your sentence in a home/electronic incarceration program or to participate in any work-release or non-consecutive days program.

DATE OF JUDGMENT ...... 107 $ ______110 $ ______

112 $ ______113 $ ______

119 $ ______120 $ ______

DEFERRED PAY DUE DATE: ...... 121 $ ______132 $ ______

...... 133 $ ______137 $ ______

MAY PAY IN INSTALLMENTS: Ž Yes Ž No 140 $ ______143 $ ______

181 $ ______203 $ ______

206 $ ______229 $ ______

260 $ ______265 $ ______

305 $ ______410 $ ______

450 $ ______451 $ ______

452 $ ______452 $ ______

520 $ ______$ ______

NOTE: Fees not shown in total shown at right: ___ $ ______$ ______

ŽCourt reporter fees GROSS DUE: $______

ŽCourt-appointed attorney fees (see note at left)

CASH BOND TO BE APPLIED TO FINES AND COSTS: $______

(Va. Code §§ 19.2-121, 19.2-369 AND 19.2-386.1) NET DUE: $______

COPY OF THE ABOVE DELIVERED TO THE DEFENDANT IN PERSON.

DATE: ...... Defendant’s signature ______

DATE: ...... ______, Bailiff/Clerk/Deputy Clerk

COPY OF THE ABOVE MAILED TO DEFENDANT AT ADDRESS IN FILE.

DATE: ...... ______, Deputy Clerk

FORM CC-1351 (w) 9/99 PC