Financial Inquiry (Payment Plan Community Service Indigency)

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

IF MARRIED, FILL OUT THIS SECTION FOR SPOUSE

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

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.None of the above apply to me.

Name of federal program (if applicable)

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

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

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 dependants?*

YesNo

Dependent's Name* Age* and relationship to you:
*

Dependent's Name Age and relationship to you:

Please add any additional dependents here:

Your residence is:*

RentedFinancedOwnedFree to live

Do you have any open credit accounts?*

YesNo

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

Rows	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*

APPLICATION FOR TIME PAYMENT, EXTENSION, OR COMMUNITY SERVICE