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Travis County Courts Payment Plan Application
Complete this application in its entirety. Do not leave any blank fields. If an item does not pertain to you, fill in the blank with “n/a” (not applicable).
Defendant Information
Full Name
*
First Name
Last Name
Nickname/Maiden Name
Date of Birth
*
/
Month
/
Day
Year
Date
Email
*
example@example.com
Are you a student?
*
Yes
No
Student Status
Part Time
Full Time
College/University
Physical Address
*
Street Address
Apartment or Lot Number
City
State / Province
Postal / Zip Code
Is your mailing address the same as your physical address?
*
Yes
No
Mailing Address
Street Address
Apartment or Lot Number
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Out of Country Phone Number
Please include the Country Code and Area Code
Drivers License Number
Drivers License State
Case Number(s)
*
If there's multiple, please separate with commas
Employment Information
Employer
*
Length of Time
*
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References
Reference 1: Relative
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2: Relative
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3: Other Contact
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 4: Other Contact
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Assets
Vehicle #1
Make
Model
Year
Plate Number
State
Vehicle #2
Make
Model
Year
Plate Number
State
Additional Comments
Additional Comments
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Monthly Household Income
Monthly Household Income Received
*
Rows
Monthly Income Received ($)
Net Pay (take home)
Unemployment
Worker's Compensation
Accident Benefits
Social Security/Disability
Retirement/Pension
Child Support
Alimony/Maintenance
Parent/Guardian Support
Interest/Dividends
Rental Property
SNAP
Housing Assistance
Total Monthly Household Income
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Monthly Expenses Paid
Monthly Expenses Paid
*
Rows
Monthly Expenses Paid ($)
Mortgage/Rent
Second Mortgage
Utilities: Electric
Utilities: Gas
Utilities: Water
Telephone
Cable/Satelite TV
Internet Service Provider (ISP)
Food
Vehicle(s): Loans, Insurance
Medical
Life/Health Insurance
Child Support
Probation Fee
Bank/Store credit cards
Other
Total Monthly Household Expenses
Office Use Only
Monthly Income
- Monthly Expenses
= Disposable Income
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Acknowledgement and Declaration
Under penalty of perjury, I hereby certify the foregoing as being a complete and accurate statement of my current financial condition. I authorize Centralized Collections, its employees, or agents to conduct a complete and thorough investigation of my statement. I understand this investigation could include direct verifications of all information given and the obtaining of reports from credit reporting agencies. It is with this understanding and acknowledgement that I formally request an extension of time for payment of the fine and court costs now due and payable to the County of Travis as set forth in the Court Order.
*
Signature of Defendant
*
Today's Date
/
Month
/
Day
Year
Date
Submit
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