JUSTICE OF THE PEACE PCT

JUSTICE OF THE PEACE PCT. THREE
PAYMENT PLAN APPLICATION- APLICACIÓN DEL PLAN DE PAGO
INSTRUCTIONS: PLEASE FILL OUT THIS APPLICATION. PROVIDE ALL THE INFORMATION REQUESTED. PROVIDING FALSE
INFORMATION TO THE COURT IS A CRIMINAL OFFENSE. PAYMENT OF $50.00 MUST BE INCLUDED WITH APPLICATION.
APPLICATION AND PAYMENT MUST BE SUBMITTED WITHIN 10 DAYS OF CONTACTING COURT.
INSTRUCCIONES: FAVOR DE LLENAR ESTA SOLICITUD. PROPORCIONAR TODA LA INFORMACIÓN SOLICITADA.
PROPORCIONAR INFORMACIÓN FALSA A LA CORTE ES UN DELITO PENAL. PAGO DE $ 50.00 SE DEBE INCLUIR CON LA
APLICACIÓN. SOLICITUD Y PAGO DEBE PRESENTARSE DENTRO DE LOS 10 DÍAS DE ENTRAR EN CONTACTO CON
CORTE.
NAME: ______________________________________________________________________________________
(NOMBRE)
LAST
FIRST
(Apellido)
MIDDLE
(Segundo Nombre)
(Nombre)
Verified
STREET ADDRESS: ___________________________________________________________________________________________
(DIRECCION DE ENVIO)
PHONE (
(Telefono)
P.O. BOX OR STREET
(Caja postal o Calle)
APT
CITY
(Ciudad)
STATE
(Estado)
ZIP
(Codigo Postal)
) ______________________ If no phone, number where you can be reached ( ) _________________
( Segundo Telefono)
CELL PHONE: (
) _____________________ (Celular)
Sex:_______ Date of Birth: ___________________ Driver License No. _____________________________
(Sexo)
(Fecha de Nacimiento)
(Numero de licencia para manajar)
Married
(Casado)


Single
Separated
(Soltero) Separado)


Divorced
(Divorciado)
____ (Grade Level Completed)
Education Level
(Grado de Educacion)
Friends or References: Name _____________________ Relationship: __________ Phone ( ) ___________
Must have 2 Names : Name _____________________ Relationship: __________ Phone ( ) ___________
(Amigo o Referencia) (Nombre)
( Relacion)
(Telefono)
ASSETS: If you are not working, state why. If you are in school, state which one.
 I am working  I am not working because: ___________________________________________________
(No esto trabajado porque:)
 I am attending school at:
_____________________________________________________________________________
(Esto registrado el la escula)

Verified
Employer: ___________________________
Spouses Employer: ________________________
(Empleador)
(Empleador)
Address _____________________________
Address__________________________________
(Direccion)
(Direccion)
Phone ( ) ___________ Position _____________
(Telefono)
(Puesto)
Phone ( ) ___________ Position _____________
(Telefono)
(Puesto)
How Long?_______ When is payday? _________
(La Duracion)
(Que dia le pagan?)
How Long?_______ When is payday? _________
(La Duracion)
(Que dia le pagan?)
Salary: $______Hourly Wage: $ _________
(Salario)
(Salario por Hora
Salary: $______Hourly Wage: $ _________
(Salario)
(Salario por Hora)
Monthly Pay: $____________
Monthly Pay: $______________
(Salario Mensual)
(Salario Mensual)
PLEASE CHECK ANY OTHER SOURCE OF INCOME YOU RECEIVE: (INDIQUE OTOR TIPO DE SUELDO)
Social Security Welfare Food stamps Retirement Unemployment Disability Child Support
(Asistencia de Social)
REVISED 9/13
(Retiro de seguridad social)
(Desempleo)
(Deshabilitad)
(Sostenimiento de ninos)
PAYMENT PLAN APPLICATION
PAGE 2
Other Than Yourself, How Many People Do You Support Directly:
(Cuantas Personas Mantienes)
_______
Number
(Numero)
________________________________________
Relationship
(Relacion)
_________________________
Ages
( Edad)
ACCOUNTS INFORMATION
Bank ______________________ Checking Balance $ _____________ Savings Balance $ _______________
(Nombre de Banco)
( Balance de cheques)
(Balance de ahorros)
Major Credit Card Name __________________ Bal. Owed $_______ Monthly Amount Paid $_______________
(Nombre de Compania de Credito)
(La Balance debida)
(Pago Mensual)
Major Credit Card Name __________________ Bal. Owed $________ Monthly Amount Paid $_______________
(Nombre de Compania de Credito)
(La Balance debida)
(Pago Mensual)
MONTHLY EXPENSES (GASTOS MENSUALES)
SUB-TOTAL $______________
Mortgage/Rent
(Renta/Hipoteca)
$ _____________
Pager/Cellular
(Pager/Celular)
Utilities – Gas/Light/Water
(Servicio Pubilco)
$ _____________
Vehicle Pmt/Insurance
$ _____________
(Pago de Vehiculo/Seguro)
Cable Television
(Cablevision)
$ _____________
Additional Creditors
(Acreedores)
$ _____________
Telephone (Home)
(Telefono)
$ _____________
Groceries
(Comida)
$ _____________
SUB-TOTAL
$ _____________
Other expenses
$ _____________
GRAND TOTAL
$ _____________
$ _____________
ACKNOWLEDGEMENT- EN RECONOCIMIENTO DE
 I UNDERSTAND A TIME PAYMENT FEE OF $25.00 WILL BE ADDED TO MY BALANCE IF NOT PAID IN 30
DAYS. ENTIENDO QUE UN PAGO DE $25.00 SERÁ AGREGADO A MI SALDO SI NO SE PAGA EN 30 DÍAS.
UNDER PENALTY OF PERJURY, I HEREBY SWEAR OR AFFIRM THAT THE FOREGOING AS BEING A
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 FINE/FEES AND COURT COSTS NOW DUE AND PAYABLE TO THE
JUSTICE OF THE PEACE, PCT. THREE.
BAJO PENA DE PERJURIO, JURO O AFFIRMO QUE EL PRECEDIDO ES UNA COMPLETA Y EXACTA
DECLARACION DE MI ACTUAL CONDICION FINANCIERO. ES CON ESTA COMPRESSION Y
RECONOCIMIENTO QUE SOLICITO UNA EXTENSION DE TIEMPO POR EL PAGO DE LA MULTA Y LOS
COBRES DE CORTED DEBIDO AL JUEZ DE PAZ #3.
DEFENDANT’S SIGNATURE (Firma)_____________________________ DATE (Fecha) _________________
REVISED 9/13