ࡱ> 352` 7bjbjss P( '''8(TV(lT<h())))m+3,|,@;;;;;;;$=h$@;E0K+"m+00;))y<2220X8));20;2268/:)( 0<,'1d9o:4$<0T<9@Ax1A8/:A/:@,-2a.|.,,,;;2X,,,T<0000!D! CITY OF NEWARK REQUEST FOR ADVANCE DEPOSIT HARDSHIP WAIVERCitation No:  FORMTEXT       RequiredDate Issued:  FORMTEXT      This form can be filled out electronically by tabbing from field-to-field. Then print, sign and date.NAME:  FORMTEXT      ADDRESS:  FORMTEXT       I request a waiver of the advance deposit because: (If more room is needed, please attach another page.)  FORMTEXT      Your waiver must be filed with the City Clerk s Office, City Hall, 37101 Newark Blvd., Newark, CA within ten (10) days of the receipt of the Administrative Citation. Please provide copies of documents verifying sources of income. (Supporting documents may include: social security, general assistance, AFDC, current paycheck, etc.)Persons supported:  FORMCHECKBOX  Self  FORMCHECKBOX  Children (#  FORMTEXT       )  FORMCHECKBOX  Spouse  FORMCHECKBOX  Other (#  FORMTEXT       ) TOTAL:  FORMTEXT       Type of supporting documentation provided:  FORMTEXT      I declare under penalty of perjury that the foregoing statement and informvx óÝufYOCóh}CJOJQJ^Jh}OJQJ^Jh5OJQJ\^JhhCJOJQJ^J"h56CJOJQJ\]^J*jhCJOJQJU^JmHnHu+jhh#eCJOJQJU^JjhCJOJQJU^JhCJOJQJ^Jh5CJOJQJ\^JhCJOJQJ^J*jhCJOJQJU^JmHnHu x VM?xx$If^ $$Ifa$xkdt$$Ifl40Bn(`,0(64 laf4  xx$If^gd $8$If^8a$$8$If^8a$777           ٶ}iZK8K%jh5CJOJQJU\^Jh5CJOJQJ\^Jh}5CJOJQJ\^J&hk?_hk?_5CJOJQJ\^JaJ&hk?_hk?_6CJOJQJ\^JaJ hk?_hk?_CJOJQJ^JaJhk?_OJQJ^Jh}OJQJ^Jh}>*CJOJQJ^J*jhCJOJQJU^JmHnHujhCJOJQJU^J+j&hh#eCJOJQJU^J    $$Ifa$vkd$$Ifl40Bn( ,0(64 laf4  s$ $If^a$gdk?_xkdV$$Ifl4L0Bn( ,0(64 laf4 & ( "ckd$$Ifl4n((0(64 laf4 xx$If^gdekd$$Ifl4 n((0(64 laf4   " $ ( : > @ T V X b d f h j > ӺӫuaUC"h}56CJOJQJ\]^Jh}CJOJQJ^J&jhOJQJU^JmHnHu'jhh#eOJQJU^JjhOJQJU^JhOJQJ^Jh}OJQJ^Jh}5CJOJQJ\^J0jh5CJOJQJU\^JmHnHu%jh5CJOJQJU\^J1jhh#e5CJOJQJU\^J( f h j > f p_I$ e'x$Ifa$gd$ 'xx$Ifa$-DM ]^gdekd $$Ifl4n((0(64 laf4 <<$If^gd> @ T V X b d f h Z [ \ ]    쟓rfZH9*h}5CJOJQJ\^Jh}5CJOJQJ\^J"h}56CJOJQJ\]^Jh}CJOJQJ^JhCJOJQJ^Jh5CJOJQJ\^J"h56CJOJQJ\]^Jh}CJOJQJ^Jhh}CJOJQJ^J0jhhCJOJQJU^JmHnHu+jhh#eCJOJQJU^JhhCJOJQJ^J%jhhCJOJQJU^Jf h [ \ 3[kd$$Ifl\((064 la$ 'xx$Ifa$gd]kd $$Ifl@ \((064 la\ ]    }bC  j <<$If^`gd$ @ <<$If^`a$ckd $$Ifl4\((064 laf4 xx$If-DM ]^gd  ' ( ) * . / 0 > ? @ A J L N O Y Z   2}e}N}-jh>*CJOJQJU^JmHnHu.jxhh#e>*CJOJQJU^J"jh>*CJOJQJU^Jh>*CJOJQJ^J+jhh#eCJOJQJU^Jh}5CJOJQJ\^Jh}CJOJQJ^J+jhh#eCJOJQJU^JhCJOJQJ^JjhCJOJQJU^J2468DFHdfhjtz~;ٲ;͏}e}N};A}h}>*CJOJQJ^J-jh>*CJOJQJU^JmHnHu.j hh#e>*CJOJQJU^J"jh>*CJOJQJU^Jh>*CJOJQJ^J+j` hh#eCJOJQJU^JhCJOJQJ^Jh}5CJOJQJ\^Jh}CJOJQJ^JjhCJOJQJU^J+jhh#eCJOJQJU^J@BDXZ\fhjֲֿ{k{Uk?k0hh}CJOJQJ^J*jhCJOJQJU^JmHnHu+jO hh#eCJOJQJU^JjhCJOJQJU^JhCJOJQJ^Jh}5CJOJQJ\^Jh}5CJOJQJ\^Jh}>*CJOJQJ^Jh>*CJOJQJ^J-jh>*CJOJQJU^JmHnHu"jh>*CJOJQJU^J.jH hh#e>*CJOJQJU^Jjzl 'xx$Ifckd $$Ifl4\((064 laf4"  jd!<<$If^`gdjl64`4j P'~xx$If]~gd$~xx$If]~^a$gdekd $$Ifl4\((064 laf4jl464L4N4\4^4`4b4d4f44444444444455ĴѩymWyњymA+jhh#eCJOJQJU^J+jYhh#eCJOJQJU^JhCJOJQJ^JjhCJOJQJU^Jh}5OJQJ\^Jh}h5CJOJQJ\^JhhCJaJh}56OJQJ\]^Jh}>*CJOJQJ^Jh}5CJOJQJ\^JU"h}56CJOJQJ\]^Jh}CJOJQJ^Jation is true and correct. Signature: Date: For City of Newark use ONLYDeposit Waiver:  FORMCHECKBOX  Denied  FORMCHECKBOX  Granted Reason for Denial: Signature: Date: PROOF OF SERVICE: On following ordinary business practices, this decision was placed for collection and mailing by first class mail at City Hall, City of Newark, 37101 Newark Blvd., Newark CA 94560 in a sealed envelope with postage fully prepaid. 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