Page 1 COMAL COUNTY COURT AT LAW

COMAL COUNTY COURT AT LAW-COMPLIANCE AND COLLECTIONS UNIT
APPLICATION FOR PAYMENT OF COURT COSTS, FINE AND FEES
CAUSE NO:
(FOR OFFICE USE ONLY)
ANSWER ALL QUESTIONS ******IF NOT APPLICABLE, PLACE "N/A"
NAME:
_
(Nombre)
Last (Apelido)
STREET ADDRESS:
(Direcion)
Number
(Numero)
MAILING ADDRESS:
(Direcion De Envio) Number
(Numero)
PHONE (
(Telephono)
Street
(Casse)
Apt.
Street
Apt.
_
Zip
State
(Estado) (Codigo Postal)
City
(Ciudad)
----:
State
(Estado)
City
(Ciudad)
(C~sse)
----:=-­
_
Zip
(Codigo Postal)
_ _ _ _ _ _ _ _ _ _ If no phone, number where you can be reached (
(Secundo Telefono)
SOCIAL SECURITY NUMBER:
(Numero de Seguridad social)
CELL PHONE: (
(Cellular)
SEX:
(Sexo)
Middle (Segundo Nombre)
First (Nombre)
_
_
DRIVERS LICENSE: _ _ •
(numero de icencia para manejar)
DATE OF BIRTH:
(Fecha de Nacimiento)
_
SINGLE _ _ MARRIED_ _ SEPARATED_ _ DIVORCED_ _ EDUCATION LEVEL
(Solitero)
(Casado)
(Separado)
(Divorciado)
(Grado de Educacion)
_
FRIEND (
(Amigo)
)Phone
- -No.-(Telefono)
- - - - - - -Relationship
---- - - - - - - -Name
- -(Nombre)
-------­
(relacion)
FRIEND (
(Amigo)
)-:-----------------------~----:----:------Phone No. (Telefono)
Relationship (relacion)
Name (Nombre)
ASSETS: If you are not working, state why, If you are In school. state which one
Employer:
(Empleador)
Salary: $.
(Salario)
Name
(Nombre)
_
(
)
Area Code Phone No.
(Area)
(Telefono)
Address
(Direcion)
Hourly Wage $
(Salario por Hora)
_
---:-:'
Position
(Puesto)
~___:_--
How Long
(La Duration)
Take Home Monthly Pay $
(Salario Mensual)
_
weekly
bi-weekly
monthly What day do you get paid?
_
How often are you paid?
(Con que frecuencia son usted pago) (semanalmente) (revista bisemanal) (mensualmente) (Que dia Ie hace es pagado)
PLEASE CHECK ANY OTHER SOURCE OF INCOME YOU RECEIVE: C1ndigue otro tlpo de sueldo)
_ _ Welfare _ _ Social Security _ _Retirement _ _ Unemployment _ _ Child Support
Disability
(Assistencia de social)
(Retiro)
(Desempleo)
(Sostenimlenta de Ninos) (Incapcidad)
AGES:
Other than yourself, how many people do you support directly:
(Cuantas Personas Mantienes Number Relationship
(Edad)
(Numero) (Relacion)
CREDITORS (Mortgage Companies, Banks, Credit Cards, Finance Companies, Department Stores, etc.)
.(de Creditos y Deudas)
Company Name (Nombre de Compania)
_
$,------------ $,----------­
Balance owed (de pagos) .
Monthly payment (Pago Mensual)
,-----------:-­
- : : - - - - - - - - - - - - - - - - $----~-------$Monthly
payment (Pago Mensual)
Company Name (Nombre de Campania)
Balance owed (de pagos)
Page 2 Application for Extension of credit
Bank Accounts (Banco de la quinto):
Checking Balance $
(Cuenta de Cheques)
Name of Bank
(Nombre de Banco)
Savings Balance $,
(Cuenta de Ahorros)
_
SUMMARY: ISumario)
Monthly Income (Salario Mensual):
Current Salaryllncome $.
(Salario)
Child Support/Alimony $,
(Sostenimiento de Ninos/Pension)
Spousal Income (EsposolEsposa Salario) $.
Other Income $,
(Ortro Salario)
_
_
Monthly Expenses (Gastos Mensuales):
Child Support/Alimony $,
(Sostenimiento de NinoS/Pension)
Cable Television $.
(Cablevision)
Mortgage/Rent $,
(Renta)
Telephone $,
(Telefono)
.Vehicle Payment/Insurance $,
(Pago de Vehicu'lo/Aseguramiento)
Groceries $
(Comestibles)
Utilities~Gas/LightlWater
$,
_
(Servicio Publico)
Pager/Cellular $,
Day Care $
(Cuidado de dial
Gasoline $.
(Gasolina)
_
Medical Expenses $.
(Gastos de medicial)
Creditors $
(Acreedores)
_
_
ACKNOWLEDGEMENT AND DECLARATION (Reconoclmiento Y Declaracionl:
I authorize the compliance department to run a credit report to verify the accuracy of same. Under Penalty of perjury, I hereby
certify that the foregoing is a true, complete and accurate statement of my current financial condition. It is with this
understanding and acknowledgement that I formally request an extension of time for payment of the fineslfees and court costs
now due and payable to Comal County.
y doy permisio a al departamento para obtener un reporte de credito para verificacion del mismo. Bajo pena de perjurio,
certifico que'el precedido es una cornpleta y exacta declaracion de mi actual condicion financiero. Es con esta compresion y
reconoclmiento que solicito una extension de tiempo porel page de la multa y los cobres de corte debido al cuidad de Comal
County.
Defendants Signature
_
Printed Defendants Signature
Date ~
_I
_
_
FOR INTERNAL USE ONLY
Home or Contact Phone Number Verified:
YES
Employment or Source of Income Verified:
YES
Interviewed By:
REMARKS:
_
NO
_
NO
_
_
Verified By:
_