COLLECTIONS PAYMENT PLAN

RANDALL COUNTY COLLECTIONS
RANDALL COUNTY MANAGED ASSIGNED COUNSEL
STANDARD PAYMENT PLAN APPLICATION
Case Number*
HOW MUCH CAN YOU PAY TODAY*
HOW MUCH CAN YOU PAY MONTHLY*
Date of Birth*

MonthDayYear
Date
Social Security*
DLID
DL/ID NUMBER*
DL/ID ISSUED FROM WHAT STATE*
Last*
First*
Middle
Maiden Name
MAILING ADDRESS Street*
Apt
CityState*
Zip*
Primary Phone*
Format: (000) 000-0000.
Message/Alternate Phone
Format: (000) 000-0000.
Email Address REQUIRED*
example@example.com
Contacts: List People who know how to always contact you. **Required to be Completed**
Reference 1 Name of Person *
Relationship to Reference 1*
Reference 1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Name of Person*
Relationship to Reference 2*
Reference 2 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
ACKNOWLEDGEMENTS AND DECLARATIONS

Under penalty of perjury, I hereby certify the information I have supplied is true and accurate. I understand all contact information can and will be used. I am able to pay on or before the due date as described in the attached Payment Plan. I understand how much I owe monthly, the date my payment is due, and how many payments I am required to make. I understand that I can request a review of my financial information (ability to pay) to see if my payments can be lowered or receive additional time to pay than what is listed on Payment Plan. I DO NOT want Randall County staff to review my financial information as I can successfully make the payments described in the attached Standard Payment Plan, WITHOUT undue hardship to myself, or my dependents. I also understand that failure to pay may result in a warrant, omni and scoff and additional fees may apply. It is with this understanding and acknowledgment that I formally request an extension of time to pay fine and courts costs now due and payable to Randall County.

*PLEASE NOTE: IF YOU ARE APPEARING IN PERSON, A SIGNATURE IS REQUIRED. YOUR PAYMENT PLAN WILL BE NEGOTIATED WHEN YOU ARE CONTACTED BY A REPRESENTATIVE.*
TODAYS DATE*

MonthDayYear
Date
SIGNATURE REQUIRED*

Clear
Randall County Collections 2309 Russell Long Blvd Ste 138 Canyon, TX 79015 Office: 806-468-5512 Email: rcje@randallcounty.gov
Should be Empty:

RANDALL COUNTY COLLECTIONS

STANDARD PAYMENT PLAN APPLICATION

Contacts: List People who know how to always contact you. **Required to be Completed**

Contacts: List People who know how to always contact you. Required to be Completed