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Application For Payment Plan

  1. Last / First / Middle
  2. Apartment*
  3. Example: (555)555-5555
  4. Name & Phone of Friend/Family Member
  5. Your information is needed below:
  6. Are you currently employed?*
  7. I get paid:*
  8. Do you have other income sources (SSI, FIP, Bridge Program, Other, etc.)?*
  9. Looking for work?
  10. Family Status:*
  11. Do you pay child support? *
  12. Do you receive child support? *
  13. How would you like your payment plan set up?*
  14. The court will try to accomodate
  15. The court will try to accommodate
  16. Would you like to receive Text Message Reminders regarding payments? *
  17. 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.
  18. Select today's date only
  19. Leave This Blank:

  20. This field is not part of the form submission.