500-00423 – Request for Extension of Time to Pay (03/2019) Page 1 of 1
Vermont Judicial Bureau
PO Box 607
White River Junction, VT 05001
www.vermontjudiciary.org
JUD.VJB@vermont.gov
Request for Extension of Time to Pay
DEFENDANT INFORMATION
Name: ____________________________________________________________
Mailing Address Street: ______________________________________________
City: _____________________________ State: ______ Zip: ___________
Date of Birth: _________________________ Phone: ______________________
Email Address: ________________________
COMPLAINT NUMBERS
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
REQUEST
I request more time to pay the Judgments for the Complaints listed above.
I have enclosed a check/money order for a partial payment of $____________________.
Minimum Partial Payments:
$30 for each Complaint for up to 3 Complaints as listed above
$100 for all Complaints for 4 or more Complaints as listed above
Date: ________________ _______________________________
Signature Required
_______________________________
Printed Name
