Mescalero Tribal Court (2018) PO Box 227 / 159 Deer Trail Mescalero, NM 88340
PAYMENT PLAN REQUEST FORM
MESCALERO APACHE TRIBAL COURT
1. This is my request to pay my fines in payments.
My name is:
____________________________________________________
Mailing address:
______________________________________________________
_______________________________________________________
Phone: _________________________________________________
2. On (date) ___________________, the court made the decision that:
I owe (total amount): $ _____________________________________
To: (name of party you must pay): _____________________________
Mailing address: ________________________________________________
3. I am asking for permission to make payments, instead of paying the full amount all at once, because
(explain):__________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
□ If your answer will not fit in the space above, check this box and attach your answer on a separate sheet of paper.
4. I ask the court to allow me to make payments on the following terms:
a. Payment of $ _____________, on the __________ day of each □ Month □Week □ Bi-weekly
Starting (date) ___________________ until the balance is paid in full. (1
st
& 15
th
)
Note: Payments cannot exceed 10 installments.
Warning! If any payment is not made in full and on time, the court will cancel the payment plan and the
entire unpaid balance will become due and collectible. You may be subject to further sanctions by the court.
I declare under penalty of perjury under the Mescalero Apache Tribal Code 10-22-1 that the information
above is true and correct.
________________________________ ________________________________
Signature Date:
________________________________ ________________________________
Printed Name Phone Number
COURT USE ONLY
□ Approved as requested □ Approved with Modification □ Denied
Reason: ____________________________
_________________________________________
________________________________ ________________________________
Printed Name Signature
____________________
