Fill and Sign the Ignition Interlock Calibration Verification and Tamper Report California Form

STR E ET ADDR E S S : M A I L ING ADDR E S S : CIT Y AND ZIP COD E : BR A NCH NAM E : NAM E OF DEF E NDA N T : S TRE E T A DDRE SS : M A I LI NG A D DRE S S: CITY AND ZIP CODE: H O ME T E L E PH O NE N O .:W O RK TE L E PH ONE NO.: DRIV E R' S L IC E N SE NO.: T his i s th e six-m o nt h yearly repor t (if relevant). a. b. ( S I G N A T U RE OF INST A L L ER) DE F ENDANT: You r next monitorin g chec k i s (date) : . If yo u h a v e n ot ha d you r syste m serviced within seven day s of th e d u e d a te , th e syste m wil l shut d o wn a n d y o u w il l b e unab l e t o s t ar t yo u r car. I t wi ll be yo u r respons i bilit y to have you r car to w e d to th e cal i brat i o n location. Y o u r n e xt paym e nt o f $ i s d ue a t th e a b ov e mon i tori n g ch e c k. Payment must b e made in full before s e rvice is perf o rmed . If paym e nt is no t made, the system m a y shu t d o w n a nd y ou may no t b e ab le to star t yo u r car. This will resul t in a service c a ll t ha t will be y o u r respo n s i bility. You m ay be requ i r ed to m a k e a n a d ditiona l p a ymen t fo r late p ayme n ts. I acknow l edge receipt of a cop y o f t h i s form. Date: ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– – – ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– – – ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– – – – – – – – – – – – – ––––– ––––– ––––– ––––– – – – ––––– ––––– ––––– ––––– –––––SUPERIOR COUR T OF CA L IFORNIA, COUNTY OF FOR COURT US E ONLY ID- 120 DATE O F COURT ORDE R : IGN I TION INTERLOCK CALIBRATION VERIFICATION TAMPER R E PORT CA S E NUM B ER: 1 . 2 . 3 . Def e ndant's name: Insta l ler's name: Address: City, state , ZIP: Te l epho n e: V e hicles:a . b . c . Mak e Model Yea r Co l o r License Plat e N o . VI N 4 . 5 . Insta l lation date: c . 6 . 7 . 8 . 9 . Odometer re a ding: C a libration settin g : Unit s e r i al No.: Pro g r a m t o e nd (date): a . a . a . b . b . b . c . c . c . 1 0. Th e syste m is in c a libration. a . b . c . 1 1. T he syste m h a s be en i nspect ed a n d is functioni n g p r o perly. a . b . c . 1 2 . T he ign i ti on i n terl o c k devices installe d i n veh i c l es (D es cri b e/ a ddition a l comments): a . b . c . show evid e nc e o f t a mp e r i ng. 1 3 . P ay m en t o f $ + sales tax $ To t al collec t ed $ paid by a . b . c . Cre d it card Mon e y order/cashier 's check/certified check Cash/persona l check I declar e un d er p e nalty of p erjury u n de r the laws o f the State of Cal i forn ia tha t th e foregoi n g is tr u e a n d c o rrect. Dat e : Dist r i b u t i o n : C o u r t, M a n u f ac t u r er o r Ma n u f a ct u r er 's A ge nt , D e fe n d an t, Pr o b a t i on De p a rt m en t For m A p p rov e d f or O pt io n al Use (SIGNATUR E O F DEF E NDANT) P a ge 1 of 1 V e h i c l e C o d e, § 2 3 5 7 5J u dici a l Co u ncil of Cal i f o rn i a I D- 1 20 [ Re v. J ul y 1 , 20 0 5] IGNITIO N INTERLOC K CAL I BRAT I O N VER I F ICATIO N AND TAMPER REPORT (Ig n i tion I n t e r lo c k D ev i c e ) elec troni c form ã 2005 WWW.LawCA.co m L a w P u b l i s h e r s