Financial Inquiry (Payment Plan Community Service Indigency)

First Name* Last Name* Phone Number* Street Address* City* State* Zip*
Marital Status: Married Single Widowed Divorced*

SELECT ALL THAT APPLY *

I have been determined to be indigent by the federal government and I am receiving or I am eligible to receive assistance under a federal program. (Enter name of program below) I request that I be able to discharge the fine and costs by performing community service, because I have no resources to pay and I am unable to pay the fine and costs. I assert that I am unable to pay the fine and costs immediately and that the following information is documentation that I have insufficient resources or income to pay today. I request that the Court extend the payment to a later date. I request that the Court grant a time payment plan.

Name of federal program (if applicable)

Employer: blanks . Job title blank . Business Address:
Street Address City State Zip . Employer phone: Phone Number
Salary: Number

IF MARRIED, FILL OUT THIS SECTION FOR SPOUSE

Spouse's First Name Spouse's Last Name Employer: blanks . Job title blank .
Salary: Number

List the source and amount of any other income you receive:

Do you have any dependants? *

Yes No

List all dependents, their ages, and their relationship to you: *

ESTIMATE YOUR AVERAGE CURRENT MONTHLY EXPENSES FOR YOU AND YOUR FAMILY:

Home mortgage payment, rent, or lot rental for trailer: *
Utilities (electricity, water, gas, telephone): *
Groceries: *
Clothing: *
Daycare: *

Do you have any open credit accounts? *

Yes No

LIST ALL OF YOUR CREDITORS (including credit cards) AND THE AMOUNT YOU OWE EACH: *

	Name	Monthly Payment
Creditor
Creditor
Creditor
Creditor
Creditor
Creditor

YOUR INITIAL BY EACH OF THE FOLLOWING STATEMENTS INDICATES THAT YOU HAVE READ THE STATEMENT, UNDERSTAND IT, AND AGREE TO IT. *

I promise that until my fines have been paid in full, I will notify this Court in person or by first-class mail of any changes of my address or telephone number at the following address (920 Estates Drive, Woodway, TX 76712) 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, costs, or restitution (if applicable) on or after the 31st day after judgment was entered that I am responsible for paying a $15 time payment fee (Section 133.103, Local Government Code). I understand that submitting false financial information to the Court constitutes the crime of tampering with a governmental record, punishable by incarceration and/or the imposition of a fine (Section 37.10, Penal Code). I swear that all the information in this application is true, correct, and complete to the best of my knowledge and belief.

Date *

Date

Signature *

Clear

APPLICATION FOR TIME PAYMENT, EXTENSION, OR COMMUNITY SERVICE