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Instructions

This form is to determine if you qualify for indigency. Please complete all portions of this form and submit. All applicants for payment extension must be interviewed; terms for payment will be established; all questions about the payment of fine and costs will be answered at that time. You will be required to submit supporting documents at the time of the interview.
Supporting Documents
- Income Tax return for year immediately preceding your court date.
- Banking Statements for the previous three months
- Proof of unemployment disposition and benefit
- Proof of Social Security Income for any household member
- Proof of child support or nonpayment of child support
- Proof of utility expenses including electric, gas, water, telephone, garbage, cable, internet, etc.
- Proof of housing expense including mortgage payment or rental agreement.
- Proof of vehicle lease, ownership, or other transportation expenses.
- Proof of medical expenses
- Proof of government financial supplements and assistance, including food, housing and Medicare subsides.
- Proof of private grants or donations
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Questionnaire

Do any of your dependents receive free or reduced lunches? *
Do you or your dependents receive Medicaid or Medicare?*
Are you able to complete Community Service in lieu of your fine?*
If you are able to complete Community Service, please complete the Community Service Request.
Community Service Request
If you are unable to complete Community Service, please explain below: *
Would you be able to pay towards your case(s) if given a payment plan? *
How long would you need to pay off your case?*
How much are you able to pay towards your case each month?*
Reason for Request*
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Personal Information

First Name*
Last Name*
Date of Birth*
Date of Birth
Address*
City*
State*
Zip Code*
Email Address*
Primary Phone Number*
Secondary Phone Number
Marital Status*
1. Single
2. Married
3. Divorced
4. Widowed
Spouse's Name*
Spouse's Date of Birth*
References
Please list one (1) references. This can be family or friends who do not live with you.
Reference 1 Name*
Phone Number*
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Employment and Income

Employer*
Name of Company or Business
Length of Employment*
Employer's Address*
Phone Number*
Salary*
Pay Frequency
1. Weekly
2. Bi-Weekly
3. Monthly
4. Annually
Do you have any dependents? *
If so, how many? *
Please list all dependent's name, age and relationship:*
Spouse's Employer*
Name of Company or Business
Spouse's Salary*
Pay Frequency*
1. Weekly
2. Bi-Weekly
3. Monthly
4. Annually
Additional Income
Please indicate the monthly amount of all other sources of income received.
Unemployment*
Welfare/TANF*
Retirement*
Social Security*
Disability*
Child Support*
HUD Housing*
Food Stamps*
Family*
Medicaid/CHIP*
Other Income*
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Personal Assets

Housing*
1. Rent
2. Own
3. Other
Landlord/Mortgage Company*
Phone Number*
Bank Name*
Amount in Bank Account*
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Monthly Expenses

Rent/Mortgage*
Child Support*
Transportation*
Utilities*
Child Care*
Food*
Medical*
Other Monthly Expense/Creditors
Balance
Monthly Payment
Other Monthly Expense/Creditors
Balance
Monthly Payment
Other Monthly Expense/Creditors
Balance
Monthly Payment
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Acknowledgements

Acknowledgements
Please carefully read the statements below and check "I understand" in order to submit your application.
I swear that the above information is true, correct, and complete to the best of my knowledge and belief. I attest that I cannot make full payment of the fine and costs levied against me by the court.*
1. I understand
I understand that the court will verify the information in my presence, and that falsifying any information on this document will result in my immediate exclusion from the program, and that all fine and costs must be paid in full to prevent the issuance of a warrant.*
1. I understand
I understand that failure to make scheduled payments as agreed upon will result in the issuance of a warrant for my arrest and a $50 warrant fee assessed.*
1. I understand
I understand that a time payment reimbursement fee per violation (C.C.P.), will be added to a person convicted of a misdemeanor and pays any part of the fine, court costs, restitution, or another reimbursement fee on or after the 31 day after the date judgment is entered.*
1. I understand
I understand that it is a crime to intentionally or knowingly file a fraudulent court document or instrument. (Government Code Section 51.904)*
1. I understand
Acknowledgement and Declaration
Under penalty of perjury, I hereby certify the aforegoing as being a complete and accurate statement of my current financial condition. I authorize the City of Baytown and the Municipal Court Payment Compliance Officer to conduct a thorough investigation of my statement. I understand this investigation could include verification of all information given. It is with this understand and acknowledgement that I formally request an extension of time for payment of fine and costs now due and payable to the City of Baytown.
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) the information you supplied is true and correct, 2) your request will not be signed in the sense of a traditional paper document, 3) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 4) you may still be required to provide a traditional signature at a later date.
1. I agree
Electronic Signature*
Date of Signing*
Date of Signing

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Email address

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