Date: ________________________
REQUEST FOR MORE TIME TO PAY Defendant, ______________________________, requests additional time to pay the forfeiture(s) on the following citation(s): 1. ______________________________________________________________ 2. ______________________________________________________________ 3. ______________________________________________________________ 4. ______________________________________________________________ I am unable to pay at this time because: ________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ I am requesting that the Judge grant me the following: 1. More time to pay until: _____________________________________ 2. Set me up on a payment plan of $________________ per week/biweekly/month. ________________________________________ Defendant ________________________________________ Social Security No. ________________________________________ Address ________________________________________ City/State/Zip Code
________________________________________ Daytime Phone