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2. REQUEST FOR EXTENDED PAYMENT PLAN
4. DATE:*
   DATE:

   DATE:
6. NAME:*
8. STREET ADDRESS:*
10. CITY, STATE AND ZIP:*
12. PHONE #:*
14. EMAIL:*
16. CITATION #:*
18. OFFENSE(S):*
20. Please choose ONE option for your payment plan:

    1. 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.
    2. 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.
22. 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.
24. SUBMIT DRIVER'S LICENSE OR ID:*
26. ELECTRONIC SIGNATURE:*
    Please type full name and date in lieu of signature
28. I WISH TO RECEIVE MY PAPERWORK IN THE FOLLOWING MANNER:*

    1. By mail to the home address provided above

    1. By email to the email address provided above
30. Please contact the court office at 281-338-6702 if you have any questions.
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field