Payment Plan Request Form

PAYMENT PLAN REQUEST FORM
PLEASE LEGIBLY PRINT OR TYPE INFORMATION BELOW:
Print name as it appears on your driver’s license or ID*
Driver’s license or ID number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Citation Number*
Date of Citation

MonthDayYear
Date
Daytime Phone Number*
Appearance Date

MonthDayYear
Date
Plea - Check one*

I hereby enter a plea of Guilty and waive appearance for trial and request a payment plan to pay my fine and costs.I hereby enter a plea of Nolo Contendere (No Contest) and waive appearance for trial and request payment plan to pay my fine and costs.
The financial affidavit serves as a report to the court of your income, expenses, and other criteria that might affect your eligibility for alternative payment options. In the financial affidavit, you will communicate to the court how you might be able to pay. Options include:
I am requesting a (Choose one below) payment plan*

WeeklyBiweeklyMonthly
I will be paying $ blanks* per week/biweekly/monthly. I understand minimums are $20 weekly; $25 biweekly; $50 monthly.
***MANDATORY: Any payment or part of payment RECEIVED on or after the 31st day following the date of conviction must include a $15.00 time payment fee per open violation (133.103, Local Government Code)
Employer
Job Title
Employer’s Address
Name of Supervisor
Supervisor’s Phone Number
Salary*
Intervals*

MonthlyBiweeklyWeekly
Number of Dependents*
Marital Status*

DivorcedWidowedMarriedSingle
Monthly Income Information Monthly Expense Information
Current monthly gross income*
Rent/Mortgage*
Government Assistance*
Auto Payment*
Other Income*
Other Expenses*
Total Monthly Income*
Total Monthly Expenses*
**** IMPORTANT NOTICE****
I certify, under penalty of perjury, that I am unable to pay the fine and costs assessed me by the Lacy Lakeview Municipal Court in full at this time. I authorized the Lacy Lakeview Municipal Court to confirm the accuracy of the information I have provided above.

I CERTIFY THAT ALL OF THE INFORMATION ABOVE IS TRUE AND CORRECT.
Signature*

Clear
Date*

MonthDayYear
Date
Email*
example@example.com
Copy of Driver License or State Identification Card

Cancelof
Should be Empty:

PAYMENT PLAN REQUEST FORM

Monthly Income Information Monthly Expense Information

**** IMPORTANT NOTICE****

IMPORTANT NOTICE