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If different from above address
List unemployed if currently not working.
Please list at least 2 additional individuals that we may contact in the event we are unable to contact you
Please list any additional monthly expenses that may not have been listed
Under the penalty of perjury I hereby certify the foregoing as being a complete and accurate statement of my current financial condition. I authorize the Taylor County Collection Department, 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 and other agencies. It is with this understanding and acknowledgment that I formally request an extension of time payment for the fine and court costs now due and payable to Taylor County.
I promise that until my fines and court costs have been paid in full, I will notify this office of any change in my name, address, employment or telephone number within 5 days.
I promise that I will pay each payment on or before the due date. If circumstances will not allow me to do so, I promise I will notify this office on or before the due date that a problem has incurred that will prevent the payment being made on time and in full.
I UNDERSTAND THAT FAILURE TO COMPLY WITH EITHER MY PAYMENT AGREEMENT OR COMMUNITY SERVICE AGREEMENT MAY RESULT IN MY ARREST.
I have completed this form in its entirety.
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