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PAY AND FORFEIT BAIL IN INSTALLMENTS (Vehicle Code, 40510.5) TO BE FILLED OUT BY A COURT CLERK Read carefully and, if you agree, sign and return the form to the clerk. CITATION NUMBER: CASE NUMBER: 1. I am the defendant in this case and I have been charged with the following infraction violation of the Vehicle Code that does not require me to go into court: b. a. e. d. c. 2. My court appearance date has not expired and I am providing proof of correction for correctable.

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