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STR EET A D DR ES S: MAIL IN G A D DR ESS : CIT Y AN D Z IP C O DE: BRAN CH N AM E: N AM E OF D EFEN DANT : STR EET AD DRESS: MAILING A DD RESS : CIT Y A N D Z IP C O DE: HOM E T E LEP HON E N O. :WORK TEL EPHONE NO.: DR IV ER 'S LI CEN SE NO .:Th is is th e s ix -m on th ye arly r e port (if r e le va nt) .a. b. (S IGN ATUR E O F IN STAL LER) DE FE ND AN T: Y ou r n ext m onit o rin g c h eck is (d ate ): . If y o u hav e not ha d yo u r syste m s e rv ic e d w it h in s e ve n d ays of th e d u e d a te , th e syste m wil l sh ut d ow n an d y ou wi ll b e u nable to sta rt yo ur c a r. I t w ill be y o ur r e sp onsib ilit y to h ave y o u r c a r to we d to t h e calib ra tio n lo ca tio n. You r ne xt p aym en t o f $ is due at th e a b ove m on ito rin g c h ec k. P aym ent m ust b e made in fu ll b efo re s er vic e is p erfor med . I f pa ym ent is n o t m ade, th e s yste m m ay s h u t d ow n an d y ou may n o t b e ab le to s ta rt yo ur c a r. T his w ill r e su lt in a se rv ic e c al l tha t w ill b e yo ur r e sp ons ibilit y . Y ou m ay b e r e quired t o m ake an add it io na l p ay men t fo r la te pa ym ent s. I a ckn ow le dge r e ce ip t o f a c o p y of thi s fo rm . Date :           S U PER IO R C O UR T OF C A LI FO RNIA , C O UNTY O FFO R C O URT U SE ONLYID -1 20D ATE O F C O UR T O RDER:IG NIT IO N I N TE R LO CKCALIB R ATIO N V ER IF IC ATIO N TAM PE R R EP O RTCASE N UM BE R:1 . 2. 3.D efen da nt's n am e: In sta lle r's n am e: Addre ss: Cit y , s ta te , Z IP : Te le phone : Vehic le s:a . b. c.M ake Model Yea r Colo r Lic e nse P la te No.VIN4.5.In sta lla tio n d ate :c.6. 7. 8. 9.O do m ete r re ad in g: Ca lib ra tio n se ttin g: Unit s e ria l N o.: Pr o g ra m to end (d ate ):a. a. a.b . b. b.c . c. c.1 0.T he s yste m is in c a lib ra tio n.a.b.c.11.Th e s yste m ha s b e en insp ected and is f u nctio ning pr op erly .a .b.c.12. Th e ig nition in te rlo ck d evic e s in sta lle d in v e h ic le s (Desc ribe /a ddit io n al c o m ments ): a .b.c.sh o w e vid e nce of tam per ing.13.P aym ent o f $ + sales tax $ Total collect ed $ paid bya. b. c.C re di t c a rd Mo n ey o rd er/c a sh ie r's ch eck/c e rtif ie d c h eck Ca sh /p e rs o na l ch eckI decla re un de r p en alt y o f p erju ry u nd er th e la w s o f th e S ta te o f C alif o rn ia th at th e fo re going is tr u e a nd c o rre ct.D ate:Distr ibut ion: Co urt, Manuf act urer or M anu factu rer's Ag ent , De fend an t, Pro bat ion Dep artme nt Form Ap proved fo r O pti on al U se(S IG NATU RE O F DEFEN DAN T) Pa ge 1 of 1 Vehi cle Cod e, § 2 357 5 Jud ic ial C oun cil o f C alif o rn ia ID-12 0 [ R ev. July 1, 20 05 ]IG NIT IO N IN TE R LO CK CALIB RATIO N VER IF IC ATIO N AND T A M PER R EPO RT (Ig nit io n In te rl ock De vic e)ele ctr o nic f o rm  2 005 WWW.LawCA.com La w P ublis h ers