PAYMENT PLAN & LICENSE REINSTATEMENT PROGRAM

FINANCIAL AFFIDAVIT AND PROGRAM APPLICATION

This program is designed to maximize your potential to pay off your fines. Payment options may or may not be approved.

Driver's License Number

Phone Contact Information

Home (type NA if not applicable)

Cell (type NA if not applicable)

Work (type NA if not applicable)

Alternate Personal Contact

Name *

Relationship *

Phone (type NA if not applicable) *

Are You Currently Employed?

Name of Employer

Hours Worked Per Week

Length of Time with this Employer (please indicate months or years)

How Frequently Do You Get Paid?

Monthly Income

Do You Have Any Other Sources of Additional Income?

List Sources Of Income

Amount of Additional Income

Does Anyone Else Help You Pay Your Monthly Expenses?

If Yes, List Name and Relationship of Person that Helps You with Monthly Expenses

Number of Dependents

Do You Pay Child Support?

Dollar Amount of Monthly Child Support Paid

Dollar Amount of Rent/Mortgage Paid Monthly (type NA if not applicable)

Dollar Amount of Utilities Paid Monthly (water, electric, sewer, gas -type NA if not applicable)

Dollar Amount of Phone Bill Paid Monthly (landline and/or mobile- type NA if not applicable)

Dollar Amount of Cable Invoice Paid Monthly (type NA if not applicable)

Dollar Amount of Any Other Debt (type NA if not applicable)

Current Checking Account Balance (type NA if no checking)

Current Savings Account Balance (type NA if no savings)

Current Retirement Account Balance (type NA if no retirement)

Real Estate Value (type NA if not applicable)

Do You Have a Vehicle?

Vehicle Make

Vehicle Model

Vehicle Year

What Month Are Your License Plates Renewed?

Do You Need License Plates Now?

Do You Have Pending Criminal Charges?

What County(s) Do You Have Pending Charges In?

Total Amount Owed in Fines

Are You On Probation or Parole Now?

Probation/Parole Officer's Name

Were You Granted a Deferred Judgement?

I certify under penalty of perjury that the statements I make on this financial affidavit are true and correct. Further I request that this information be considered as an application for a Dallas County:

I would like to request:

A Monthly Payment Plan

Driver's License Reinstatement Program

Both Payment Plan and Driver's License Reinstatement Program

Wage Assignment (Auto Deduct from Paycheck)

Amount I Am Able to Pay Per Month (amount is not guaranteed to be approved)

Amount I Would Like Deducted From Each Check

Please Include Proof of Income (Check Stub, Proof of SS/Disability Benefit, Etc.)

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

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