Please complete all portions of this form and submit. Once received, you will be scheduled for a Payment Review Hearing to discuss your options with the Judge. You will be required to bring supporting documents to this hearing.
Please list two (2) references. These can be family or friends who do NOT live with you.
Name of Company or Business
Please indicate the monthly amount of all other sources of income received.
Year Make Model
DO NOT PUT ACCOUNT NUMBERS
Please carefully read the statements below and check "I understand" in order to submit your application.
Under penalty of perjury, I hereby certify the aforegoing as being a complete and accurate statement of my current financial condition. I authorize the City of Baytown and the Municipal Court Payment Compliance Officer to conduct a thorough investigation of my statement. I understand this investigation could include verification of all information given. It is with this understand and acknowledgement that I formally request an extension of time for payment of fine and costs now due and payable to the City of Baytown.
By checking the "I agree" box below, you agree and acknowledge that 1) the information you supplied is true and correct, 2) your request will not be signed in the sense of a traditional paper document, 3) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 4) you may still be required to provide a traditional signature at a later date.
This field is not part of the form submission.
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