Fillable DENTON COUNTY COLLECTIONS COMPLIANCE APPLICATION FOR PAYMENT PLAN/APLICACION (Denton County, Texas)

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DENTON COUNTY COLLECTIONS COMPLIANCE APPLICATION FOR PAYMENT PLAN/APLICACION (Denton County, Texas)

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The DENTON COUNTY COLLECTIONS COMPLIANCE APPLICATION FOR PAYMENT PLAN/APLICACION (Denton County, Texas) form is 3 pages long and contains:

  • 1 signature
  • 18 check-boxes
  • 93 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Denton County, Texas

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DENTON COUNTY COLLECTIONS COMPLIANCE
APPLICATION FOR PAYMENT PLAN/APLICACION PARA PLAN DE PAGO
Cause (Case) Number(s) ___________________________________ Date/Fecha ______/_____/_____
FOR OFFICE USE ONLY
ENGLISH
SPANISH
Retained Attorney_______ Court Appointed Attorney_______ Pro Se_______ 6A Status______________________________
Bail Bond or Cash Bond If cash bond, how much$_________ Are you applying cash bond to fees due? How much $_________
Down Payment _______Yes _______No If yes: Amount $___________________ Method:_____________________________
Personal Information/Infomacion Personal
Name: (First, Middle, Last) /Nombre (Primero, Medio, Appellido)
Date of Birth/Fecha de Nacimiento:
Street Address/Domicilio Calle
Apt/Lot/Lote:
City & State/Ciudad y Estado:
Zip Code/Codigo
Verified
Primary Phone Number/Numero Principal:
Cell Phone/Celular:
Verified
Social Security No./Numero de Seguro Social:
Driver License or ID Number/ Numero de Licencia o Identificación:
Marital Status/Estado Civil: (Check one/marca uno)
Single/Soltero______ Married/Casado______ Seperated/Separado______ Divorced/Divorciado_______ Widow/Viudo______
Name of Spouse/Nombre de su Esposo o Esposa: Spouse’s Phone Number/Numero de Esposo o Esposa:
________________________________________________ ___________________________________________________
Who do you live with/Con quien vives? Relation/Relación Phone Number/Número de Teléfono:
____________________________________________________________ ___________________________________________________
Number of Dependants Supported under age of 18/ Numero de Dependes menor de 18 anos: ______________
Personal References (over 18 years of age)/ Referencias Personales (mayores de 18 años)
Name/Nombre:
______________________________________________________________
Address/Domicilio OR Email Address/Correo Electronico:
Phone Number/Numero Telefono
Relationship/Relacion
Verified
Name/Nombre:
______________________________________________________________
Address/Domicilio OR Email Address/Correo Electronico:
Phone Number/Numero Telefono
Relationship/Relacion
Verified
Name/Nombre:
______________________________________________________________
Address/Domicilio OR Email Address/Correo Electronico:
Phone Number/Numero Telefono
Relationship/Relacion
Verified
Email Address/ Correo Electonico
Employment/Empleo
If you are not working, state why/Si no estas trabajando explique porque.
________________________________________________________________________________________
Employer Name/Nombre del Empleador:
_________________________________________
Employer Address/Direccion del Empleador:
_________________________________________
Employer Phone Number/Número de Teléfono:
_____________________________________________
Dates Employed/Fecha de estar Trabajando
___________ to/de _____________
Hourly Wage/Pago por Hora: Monthly/Mensual:
$__________ $__________
Next Pay Date/Proxima fecha de Pago
_________________________________
Pay Schedule/Calendario de Pago: (Check one/Marca uno)
Weekly/Por Semana _____
Biweeky/Quincena ______
Monthly/Mensual _______
Student/Estudiante: (Check one/Marca uno) Yes/Si_____ No_____
Part Time/Tiempo Parcial____ Full Time/ Tiempo Completo____
School/University Name/Nombre de la Escuela/Universidad:
_________________________________________________
Name of Bank/Nombre de Banco: Checking Balance/Balance de Cuenta de Cheques: Savings Balance/Balance de Cuenta de Ahorros:
_________________________________ $________________________________ $________________________________
Do you receive assistance under the following/Recibe ayuda para los siguientes: Yes/Si or No
Food Stamps/Estampillas $______________ WIC Medicaid CHIPS TANF
Monthly Income All Sources/Ingresos Mensual Todo Fuentes
Take home pay/Ingresos por Mes
$
Social Security/ Seguro Social
$
Spouse take home pay/Ingresos por mes Esposo(a)
$
Disability or Retirement/Incapacidad o Retiro
$
Unemployment/Subsidio de Desempleo
$
Workmans Comp/Compensación de Trabajo
$
Child Support Received/Manutencion para Ninos
$
Financial Aid/Ayuda Financiera para Escuela
$
Contract or Cash Labor/Contrato o Dinero Efectivo
$
Cash Gift or Other/ Otro
$
EXPENSES/GASTOS
MONTHLY PAYMENT
PAGO MENSUAL
EXPENSES/GASTOS
MONTHLY PAYMENT
PAGO MENSUAL
Rent or Mortgage/ Renta O Pago de Casa
$
Uniforms/Uniformes
$
Car Payment/Pago de Auto
$
Cable TV , Internet
$
Car- Insurance/ Seguro de Auto
$
Cell/Home Phone/Celular
$
Child Care/ Cuidado de Nino
$
Medical/Gastos Medicos
$
Child Support not deducted from
pay/Manutencion Para Ninos (Pagado)
$
Interlock/Scram DWI/Monitor del Alcohol DWI
$
Water/Cuenta del Agua
$
Outstanding Loans/ Prestamos Pendientes
Gas (Home)/Cuenta del Gas (casa)
$
Type/Tipo:
$
Gasoline/Gasolina (Auto)
$
Type/Tipo:
$
Electricity/Cuenta del Electricidad
$
Credit Card Debt/ Tarjetas de Crédito
Mínimum/Mínimo
Food (Groceries)/Comida
$
VISA Balance $ _________
$
Restaurants/ Fast Food/Restaurantes
$
MasterCard Balance $ _________
$
Clothes/Ropa
$
Other Cards/Otros Tarjetas de Crédito
Balance $__________
$
Entertainment/Entretenimiento
$
Lottery/Lotto Tickets/ Loteria
$
Athletic Events/Eventos Atleticos
$
Money Sent out of the Country/ Dinero
Enviado a otro pais
$
Recreational Activities/Actividades
Recreativas
$
Alcoholic Beverages/Bebidas Alcoholicos
$
Marijuana or other Illegal Drugs/ o otras
Drogas
$
Cigarettes/Tobacco/Vape/ E-Cig/Cigarros
$
ACKNOWLEDGEMENT AND DECLARATION/ CONOCIMIENTO Y DECLARACION
I agree that the Denton County Collections and Compliance Department may contact me and my references by
telephone provided above (upon verification). The Collections Compliance department may also contact me by email,
using any email address provided.
I hereby certify that the information and statements made on this application and all information furnished in support
of the application are true and correct. I agree to give the Denton County Collections and Compliance department any
information necessary to prove statements made in this application.
Intentionally or knowingly giving false or incomplete information may result in your prosecution for the offense of
aggravated perjury, a felony. The punishment for aggravated perjury includes imprisonment not to exceed ten (10)
years and a fine not to exceed ten thousand dollars ($10,000).
____________________________________________ _________________
Defendant’s Signature/Firma del Demandado Date/Fecha
____________________________________________ _________________
Collections Compliance Department Date
Estoy de acuerdo en que el Departamento de Colecciones del Condado de Denton pueden contactarme y mis
referencias por teléfono a cualquier número de teléfono proporcionado previa verificación. El Departamento de
Colecciones también puede contactarme por correo electrónico, usando la dirección de correo electrónico
proporcionada.
Certifico que la información y las declaraciones hechas sobre esta aplicación y toda la información presentada en
apoyo de la solicitud son verdaderas y correctas. Me comprometo a dar el Departamento de Colecciones del
Condado de Denton toda la información necesaria para verificar las declaraciones hechas en esta aplicación.
Intencionalmente o con conocimiento dar la información falsa o incompleta podía dar lugar a su procesamiento de
la ofensa del perjurio agravado, un crimen. El castigo para el perjurio agravado incluye el encarcelamiento para no
exceder diez (10) anos y una multa para no exceder diez mil dólares ($10,000).
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DENTON COUNTY COLLECTIONS COMPLIANCE APPLICATION FOR PAYMENT PLANAPLICACION (Denton County, Texas)

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Completed 13 February 2021

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