Municipal Court

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Download Municipal Financial Affidavit

FINANCIAL AFFIDAVIT: PAYMENT PLAN APPLICATION

Defendant(s) Name (First/Middle/Last):

Street Address:

City, State, Zip Code:

Social Security No.:

Date of Birth:

Phone Number:

Drivers License #:

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NET INCOME:

Current monthly net (take-home) income from all sources:

(Net income is your total income including salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments, minus deductions required by law and other court-ordered payments such as child support.)

Employer:

Public Assistance:

Benefits:

Alimony:

Interest:

Odd Jobs:

Second Job:

Food Stamps:

Disability Benefits:

Pensions:

Dividends:

Other:

Self-Employment:

Unemployment:

Social Security/SSI:

Rental Income:

Annuities:

(Specify):

Total:

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EXPENSES:

Regular monthly household debt-payment and other expenses:

Mortgage/Rent:

Credit Card Payments:

Cell Phone:

Child Support:

Car Payment:

Other Debt Payments:

Food:

Alimony:

Other:

Loan Payments:

Utilities:

Child Care:

Medical Bills:

(Specify):

Total:

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ASSETS:

List the value of any individually or jointly owned assets.

Cash:

Bank Accounts:

Certificate of Deposits:

Money Market Accts.:

Other Assets:

Savings Account:

Stocks/Bonds:

Real Estate:

Vehicle(s):

Boats/ATVs:

Tax Refund Due:

Money Owed you:

Medical Bills:

(Specify):

Total:

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By typing my name on this form, I swear to or affirm the completeness and truthfulness, to the best of my ability and knowledge, of the information I have provided.

Signature of Applicant:

Date:

Taken, subscribed, and sworn or affirmed before me, by the person whose signature appears above, on this day:

Town:

FINANCIAL AFFIDAVIT: PAYMENT PLAN APPLICATION

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