Community Service Application

I assert that I have insufficient resources to pay the fine and costs immediately and that the following information is documentation that I am unable to pay. I understand that | may ask the court to grant me an extension for time to pay, a payment arrangement, or community service in lieu of payment of fine and court costs. I DO NOT WANT an extension to pay. I DO NOT WANT a payment arrangement. I DO WANT the court to allow me to perform community service in lieu of paying fines and court costs.

I was 17 years old or older when I committed the offense(s I am of sound mind. I am physically able to perform community service. I understand that if my request is granted, I will be given credit against my fine and costs at the rate of $100 per day.

I understand my right to a jury trial and that my signature on this form will have the same force and effect as a plea of guilty on the judgment of the Court. I understand that if any part of the fine, and/or costs, is still outstanding on or after the 31st day after judgment was entered that a $15 one-time payment fee will be added to each violation that has an outstanding balance.

Print name as it appears on your drivers license or ID*

Drivers license or ID number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Daytime Phone Number*

Format: (000) 000-0000.

Citation Number - 1*

Violation Charged - 1*

Citation Number-2

Violation Charged - 2

Citation Number - 3

Violation Charged - 3

Citation Number - 4

Violation Charged - 4

I hereby enter a plea of Guilty and waive appearance for trial; orI hereby enter a plea of Nolo Contendere (No Contest) and waive appearance for trial.

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. You may be asked to provide documentation proof at any time.

Employer

Job Title

Employer's Address - Complete Address including City, State, and Zip

Name of Supervisor

Supervisor's Phone Number

Format: (000) 000-0000.

Salary

MonthlyBiweeklyWeekly

MarriedSingleDivorcedWidowed

Number of Dependents

Monthly Income Information

Current monthly gross income

Government Assistance

Other Income

Total Monthly Income

Monthly Expense Information

Rent/Mortgage

Automobile Payment

Other Expenses

Total Monthly Expenses

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*

Date*

Date

Email Address*

example@example.com

APPLICATION FOR COMMUNITY SERVICE