Application for Payment Plans and Deferred Payments Personal Identification Names Case No.:

Transcription

1 Application for Payment Plans and Deferred Payments Personal Identification s Case No.: Date of Birth Sex Social Security Number Driver's License/ Identification Number Addresses Current or temporary address Street Apt. City State ZIP Permanent address, if different Street Apt. City State ZIP Mailing address, if different Street Apt. City State ZIP -- Personal Work Telephones Home phone Cell phone Office phone Facsimile Marital status: Single Married Divorced Spouse's name Spouse's address, if different Street Apt. City State ZIP Spouse's address Personal Work Spouse's telephone numbers, if different Home phone Cell phone Office phone Facsimile Residence: Rent Own Rent free Landlord/Mortgage company Co-habitation Status Do you reside with someone else? Yes No Who: Roommates Parent Significant other Do you share household expenses? Yes No Do you live rent free? Yes No 1

2 Dependents s Ages Relationships Addresses Do your dependents have any other source of income? References (not related) list 3 Address Telephone Number Address Telephone Number Address Telephone Number Employment Title/position Employer(s) Employer's address Employer's phone number of supervisor Employment dates Annual income, including commissions and bonuses Average Take Home Pay Frequency of pay Weekly Bi-Weekly Monthly day Spouse's/Significant Other's Employment Employer(s) Employer's address Employer's phone number of supervisor Title/position Employment dates Annual income, including commissions and bonuses Average Take Home Pay Frequency of pay Weekly Bi-Weekly Monthly day 2

3 Educational Status Are you a student? of school Full or part-time Financial Institutions Checking accounts of institution Balance Savings accounts of institution Balance Other accounts of institution Balance Nature of account Other Income Contract/Cash Labor, including income from babysitting, lawn mowing, temporary manual labor, etc. Social Security Welfare/Assistance Food stamps Retirement/pension/IRA Unemployment Disability Alimony/child support Rental income Farm/ranch income Business Income Royalties, Trusts, Dividends Commissions/sales Cash gifts Loans received, such as student loans used to pay living expenses, but not to secured loans related to purchases, such as automobiles Other Liabilities (Use additional sheets as necessary. Creditors Outstanding Loans of Creditors Balance owed 3

4 Periodic payment Amount Frequency Type of debt Credit Cards Visa Current balance Pay in full or pay over time MasterCard Current balance Pay in full or pay over time Fuel Current balance Pay in full or pay over time Other Current balance Pay in full or pay over time Routine expenses Mortgage/rent Utilities Water Wastewater Garbage Gas Electric Telephone (basic landline & local calls) Food (groceries) Laundry/dry cleaning School expenses Uniforms Car payments Car insurance Insurance Medical insurance Out of pocket medical payments and subscriptions Child support/alimony Household maintenance Discretionary Expenses Cell phone Text/data plans Cable TV & Internet Access Long distance calls 4

5 Restaurants (fast food) Clothes Entertainment Athletic Events Recreational Activities Recreational marijuana/controlled substances/drugs Lottery tickets Money sent out of country Alcoholic beverages Cigarettes/Tobacco Others Personal Assets Automobiles Year Make Model Monthly payments Value License Number Vessels Type of vessel Length Monthly payments Value Registration Number Pending case numbers Did you post a cash bond? Amount Are you currently on a payment plan? With CC municipal court? With another court? If so, what court? Are you currently on probation in another jurisdiction? If so, what court? If so, how long? Are you currently on parole through TDCJ or another state? If so, what authority? If so, how long? 5

6 Other financial information that the Court should consider How much cash do you have on your person? Do you have a credit or debit card on your Yes person? What is the available credit on your credit and debit card? Amount of money you can pay today: Is someone else going to help you pay Yes your fine(s) and court costs? & relationship Mailing Address Telephone No No Emergency Contact Information (2) Mailing Address Telephone Relationship Mailing Address Telephone Relationship Disabilities Are you disabled? If so, how long have you been disabled? Is this a temporary or permanent condition? What is your disability? Are you under a doctor's care? If yes, what is the name of the doctor, clinic, or hospital that is treating you? Does you disability or illness prevent you from doing community service? If yes, you must provide a letter from the doctor indicating the reason for your inability to do community service. Summary of Assets, Income, & Expenses Assets Available cash Current balance of checking and savings accounts Total Funds Available Monthly Income 6

7 Defendant's Monthly Salary (if paid biweekly -- use total take home pay for two pay checks) Spouse's or Significant Other's Salary (if paid bi-weekly -- use total take home pay for two pay checks) Other income (average on monthly basis) Total Monthly Income Monthly expenses Routine expenses Discretionary expenses Total monthly payments on credit cards and loans Total Monthly Expenses Acknowledgement and Declaration I promise that until my fines and court costs have been paid in full, I will notify this Court of any changes of my address or telephone number in person or by first class mail sent to Municipal Court, 120 N. Chaparral Street, Corpus Christi, Texas within five (5) days of the change. I understand that until my fines and court costs are paid in full I have a continuing obligation to notify the Court of any changes in my financial status that may hinder my ability to satisfy the judgment or help me satisfy the judgment. I understand that if I pay any part of the fine, court costs, or restitution (if applicable) on or after the 31 st day after judgment was entered that I am responsible for paying a $25 time payment fee ( , Texas Local Government Code). I understand that submitting false financial information to the Court constitutes the crime of tampering with a government record, punishable by incarceration and imposition of a fine ( 37.10, Texas Penal Code). I swear that all of the information in this application is true, correct, and complete to the best of my knowledge and belief. I promise to update and correct any incomplete or inaccurate information within five days of submitting this information. Date: Defendant's Signature: Sworn and subscribed before me on this day of, 20. (Judge)(Clerk)(Deputy Clerk) (Municipal Court Seal) 7

8 Collection & Compliance Section Recommendation Does 's annual income exceed the Federal poverty guidelines for the 's family size? qualifies for community service based on indigency guidelines qualifies for a standard payment plan qualifies for a reduced payment plan Monthly payment required to pay total due within 3 months $ Monthly payment required to pay total due within 4 months $ Monthly payment required to pay total due within 6 months $ Monthly payment required to pay total due within 12 months $ The recommended minimum monthly pay $ If recommended minimum monthly payment is less than the payment required to pay total due within the maximum time allowed in the guidelines, explain basis of recommendation: Date: Deputy Clerk's Signature: 8