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2. Name (as it appears on court records)*
   Last / First / Middle
3. Email Address*
5. Date of Birth*
   Date of Birth
6. Social Security Number*
7. Phone Number*

   Example: (555)555-5555

9. Address*
11. Apartment*

    1. Apartment
    2. Lot

    1. Upper
    2. Lower

    1. Suite
    2. Not Applicable
13. Apt #*
14. Lot #*
15. Suite #*
17. City*
18. State*
19. Zip Code*
21. Drivers license / State ID #
22. Issuing State
26. Are you currently employed?*

    1. Yes
    2. No
28. Employer Name*
30. Employer address*
31. Employer Phone Number*
33. City*
34. State*
35. Zip Code*
37. I get paid:*

    1. Weekly
    2. Bi-Weekly
    3. Monthly
38. Amount of take home pay received*
39. Date of my next paycheck*
    Date of my next paycheck
41. Do you have other income sources (SSI, FIP, Bridge Program, Other, etc.)?*

    1. Yes
    2. No
42. Name of source / Amount received / weekly, bi-weekly or monthly*
43. Date of month income received*
    Date of month income received
45. How are you paying bills currently?*
49. How would you like your payment plan set up?*

    1. Weekly
    2. Bi-Weekly
    3. Monthly
    4. Other
50. If other, please explain:
52. What monetary amount can you afford per payment? *
    The court will try to accomodate
53. Please select due date for first payment*
    Please select due date for first payment
    The court will try to accommodate
55. Would you prefer an electronic copy of your plan emailed to you?*

    No paper copy will be mailed

    1. Yes
    2. No
57. Would you like to receive Text Message Reminders regarding payments? *

    1. Yes
    2. No
58. Please provide cellphone number *
62. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. I have reviewed this document and the statements it contains are true to the best of my knowledge, information, and belief.

    1. I agree.
64. Electronic Signature*
65. Date*
    Date
    Select today's date only
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit Submit and Print

* indicates a required field