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Request for Extended Payment Plan
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REQUEST FOR EXTENDED PAYMENT PLAN
DATE:
*
DATE:
DATE:
NAME:
*
STREET ADDRESS:
*
CITY, STATE AND ZIP:
*
PHONE #:
*
EMAIL:
*
CITATION #:
*
OFFENSE(S):
*
Please choose ONE option for your payment plan:
I am requesting 30 DAYS to pay my fines. I understand that if my balance is unpaid at the end of 30 DAYS, I will be responsible for contacting the court and for paying any extra fees from the State.
I am requesting an EXTENDED payment plan to pay my fines. I understand that $15.00 will be added to each offense and I will then be responsible for making $60.00 biweekly payments.
I understand that this form is just a request for an extended payment plan and that nothing has been granted by the judge at this time. I understand I must submit this application with a copy of my driver’s license or ID.
SUBMIT DRIVER'S LICENSE OR ID:
*
ELECTRONIC SIGNATURE:
*
Please type full name and date in lieu of signature
I WISH TO RECEIVE MY PAPERWORK IN THE FOLLOWING MANNER:
*
By mail to the home address provided above
By email to the email address provided above
Please contact the court office at 281-338-6702 if you have any questions.
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