This form allows you to make your request for a payment plan, but does NOT GUARNTEE you will be granted a payment arraignment. You may not request a payment plan if you are under the age of 17 or charged with an offense under the Texas Alcohol Beverage Code, Tobacco offense or violation of the Texas Penal Code. All requests MUST include a payment plan request form and a photo ID. Incomplete submission will be denied. Your request will be reviewed by court staff and you will be contacted by email once a determination has been reached on your eligibility. Allow up to 10 business days for court staff to process your request. By filing a request you are waiving your right to a trial and entering a plea of NO CONTEST. By doing so this may result in a conviction on your driving or criminal record. You also are agreeing to make your first payment at the time the request is approved, without a payment, your request will be denied and your appearance before the judge will be required.

Please note, if you have been set for show cause docket and need to restart your payment plan, you must do so in person.

*Recommended amount for payment plan: $100 down, $100 a month. If further arrangements are to be made, please contact the court at 903-892-7295.

Name:*

Address:*

Apt #:

City:*

State:*

Zip Code:*

Phone Number:*

DL State:

DL #:

Date of Birth:*

Employer:

Email:*

List two (2) names of friends or family members that have contact with you on a regular basis (Phone numbers must be different from your own):

Contact #1 Name:*

Contact #1 Phone Number:*

Contact #2 Name:*

Contact #2 Phone Number:*

Read each of the following statements and check mark each one indicating you have read, understand and agree to each statement.

I assert that I am unable to pay the fine and costs immediately and that the information provided is true and correct to the best of my knowledge.

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 address listed on the installment agreement provided to me at the time of signing this paper.

I understand that I have a continuing obligation until my fines are paid in full 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 or costs on or after the 31st day after judgement was entered that I am responsible for paying a $15.00 time payment fee for each offense that has and outstanding balance.

I understand that submitting false financial information to the court constitutes the crime of tampering with a government record, punishable by incarceration and/or the imposition of a fine. (Sec. 37.10 Penal Code) I swear that all the information in this application are true, correct, and complete to the best of my knowledge and belief.

Government Photo ID:*

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