Fillable Application for Payment of Court Costs Fine Fees (Texas Secretary of State)

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Application for Payment of Court Costs Fine Fees (Texas Secretary of State)

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P.O. Box 707
Odessa, TX 79760
Jennifer Martin
County Clerk
(432) 498-4130
Fax (432) 498-4177
COMPLIANCE IMPROVEMENT PROGRAM
APPLICATION FOR PAYMENT PLAN FOR FINE, COURT COSTS AND FEES
CASE NUMBER____________________________________________________________ DATE ____________________________
(Número de Caso) (Fecha)
A. CONTACT INFORMATION
NAME: _____________________________________________________________________________________________________
(Nombre) LAST(Apellido) FIRST(Nombre) MIDDLE(Segundo Nombre)
EMAIL ADDRESS:____________________________________________________________________________________________
(Correo Electrónico)
HOME ADDRESS:____________________________________________________________________________________________
(Dirección de Casa) POST OFFICE BOX OR STREET APT CITY STATE ZIP
(Caja Postal O Calle) (Ciudad) (Estado) (Código Postal)
MAILING ADDRESS:__________________________________________________________________________________________
(Dirección de Envio) POST OFFICE BOX OR STREET APT CITY STATE ZIP
(Caja Postal O Calle) (Ciudad) (Estado) (Código Postal)
COUNTY OF RESIDENCE:_____________________ YEARS OF RESIDENCY:_______________________
(Condado de Residencia) (Años de Residencia)
PRIMARY PHONE: ( )_______________________ CELL PHONE: ( )__________________________
(Teléfono Primario) (Teléfono Cellular)
B. PERSONAL DATA
SEX:_______ DATE OF BIRTH:____/____/_____ PLACE OF BIRTH:___________________________
(Sexo) (Fecha de Nacimiento) (Lugar de Nacimiento)
SOCIAL SECURITY NUMBER: - -
CITIZENSHIP:____________ INS#:_____________________
(Número de Seguro Social) (Ciudadanía) (Número de INS)
HEIGHT:__________ WEIGHT:__________ BUILD:________________ COMPLEXION:_____________________
(Altura) (Peso) (Cuerpo) (Complejo)
HAIR:_________ EYES:___________ RACE:____________ ETHNICITY:_________________
(Color de Pelo) (Color de Ojos) (Raza) (Etnicidad)
DRIVER’S LICENSE NUMBER:______________________ OR ID NUMBER:_________________________
(Número de Licencia para Conducir) (Número de ID)
STATE:_______________ TYPE:______________________ EXPIRATION DATE:_______________________
(Estado) (Tipo de Licencia) (Fecha de Expiración)
MARITAL STATUS: SINGLE( ) MARRIED( ) DIVORCED( ) SEPARATED( ) UNMARRIED RELATIONSHIP( )
(Estado Civil) (Soltera) (Casada) (Divorciado) (Separado) (Relación Soltera)
NUMBER OF CHILDREN: ____________
(Número de Niños)
AUTOMOBILE MAKE:_______________________ MODEL AND COLOR:___________________________
(Marca de Automóvil) (Modelo Y Color)
YEAR: _________ REGISTRATION STATE: ______________ LICENSE PLATE:____________________
(Año) (Estado de Registro) (Número de la Placa de la Licencia)
C. REFERENCES
1.___________________________________________ _____________________________________________
NAME/Nombre RELATIONSHIP/Relacíon
_____________________________________________________ ( )_______________________________
ADDRESS/Dirección PHONE/Teléfono
2.___________________________________________ ____________________________________________
NAME/Nombre RELATIONSHIP/Relacíon
_____________________________________________________ ( )______________________________
ADDRESS/Dirección PHONE/Teléfono
D. WORK/SCHOOL INFORMATION
NUMBER OF YEARS OF EDUCATION:_____________ Are you a High School Student? Yes: ____ No: _____
(Número de Años de Educación) (¿Eres un Estudiante de Preparatoria?) (Si) (No)
If Yes, skip to SECTION F. Si su respuesta es Sí, continúe a SECCIÓN F.
HIGH SCHOOL DIPLOMA: Yes:___ No:___ GED: Yes:___ No:___
(Diploma de Escuela Preparatoria) (Si) (No) (Si) (No)
MILITARY BRANCH: ____________________________ TYPE OF DISCHARGE: ______________________________
(Rama Militar) (Tipo de Baja)
EMPLOYER:__________________________ ADDRESS:________________________________ PHONE( )________________
(Empleador) (Dirección) (Teléfono)
How long have you worked for current employer?
_____________________________________________________
(
¿Cuánto tiempo has trabajado para el empleador actual?)
RATE OF PAY: ________________________/HOUR OR RATE OF PAY______________________/JOB
(Salario por Hora) (Tarifa de Pago)
E. HOUSEHOLD/FINANCIAL INFORMATION
NAME OF BANK: _______________________________CHECKING: __________________ SAVINGS BALANCE:______________
(Nombre de Banco) (Balance de Cheques) (Balance de Pagos)
Other than yourself, how many people live in your home:_____________
(¿Aparte de usted, cuantas personas viven en su hogar?)
NAME/Nombre:_____________________________RELATIONSHIP/Relación:__________________ AGE/Edad:_________
NAME/Nombre: ____________________________ RELATIONSHIP/Relación: _________________ AGE/Edad:_________
NAME/Nombre: ____________________________ RELATIONSHIP/Relación: _________________ AGE/Edad:_________
NAME/Nombre: ____________________________ RELATIONSHIP/Relación: _________________ AGE/Edad:_________
MONTHLY INCOME: MONTHLY EXPENSES:
(Salario Mensual) (Gastos Mensuales)
Your Salary/Income: $______________ Child Support/Alimony: $_______________
(Salario) (Sostenimiento de Niños/Pension)
Spouse’s Salary/Income: $______________ Mortgage/Rent: $_______________
(Salario de Pareja) (Hipoteca/Renta)
Income of Others in your home: $______________ Utilities-Gas/Elec/Water: $_______________
(Ingresos de Otros en su Casa) (Servicio Publico)
Child Support you Receive: $______________ Cable: $_______________
(Sostenimiento de Ninos/Pensíon)
SSI/Food Stamps/WIC/etc....: $______________ Phone: (Teléfono) $_______________
Other Income: $______________ Car Payment/Insurance: $_______________
(Otro Salario) (Pago de Vehiculo Aseguranza
Remarks:__________________________________ Groceries: $_______________
(Mandado)
__________________________________________
Other: $________________
__________________________________________ (Otro)
__________________________________________ Other: $________________
(Otro)
__________________________________________
__________________________________________ Other: $________________
(Otro)
__________________________________________
Other: $________________
(Otro)
F. ACKNOWLEDGEMENT (Reconocimiento)
By signing below I certify that, to the best of my knowledge, the information provided by me is true, accurate, and complete. I authorize
the Ector County Community Supervision Office and the Ector County Clerk, Compliance Department and its employees to investigate
and verify all information provided by me. This may be done via phone, text, email, or other electronic means and may include contact
with myself, my references, and my employer. I understand that I may be contacted at the numbers and addresses provided regarding
my case and payments.
Al firmar a continuación certifico que a mi leal saber y entender, la información proporcionada por mi es verdadera, exacta y completa.
Autorizo al Departamento de Cumplimiento del Condado Ector y sus empleados y/o agentes a investigar y verificar toda la información
proporcionada por mi. Esto puede hacerse a través de teléfono, mensajes de texto, correo electrónico, o otros medios electrónicos y
puede incluir el contacto conmigo mismo, mis referencias, o mi empleador. Entiendo que puede ser contactado en los números y
direcciones facilitadas con respecto a mi caso y/o pagos.
Defendant’s Signature: ___________________________________________________Date: ____/____/____
Witnessed by: __________________________________________________________
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Application for Payment of Court Costs Fine Fees (Texas Secretary of State)

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Completed 24 August 2020

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