IN THE MUNICIPAL COURT
CITY OF MESQUITE
DALLAS COUNTY, TEXAS

STATE OF TEXAS VS.

CAUSE NUMBER(S) ; ; ;
I have the ability to pay monthly payments of $100 Yes   No
I was previously Court Ordered a payment plan and failed to comply with the Order Yes   No
I have insufficient resources or income to pay the Fine and Court Costs and request that the Court grant a Payment Plan, Suspend the Fine or order Community Service to discharge the fine and court costs.
I assert that I am unable to perform community service to discharge the fine and court costs due medical reasons listed in the letter from my physician which is attached.
I am receiving or I am eligible to receive assistance under a federal program:
Public HousingSNAP (food stamps)Other (name of program):

FINANCIAL APPLICATION (ABILITY TO PAY FORM)

Name Telephone Number
Email address
Address City State ZIP
Current Employer Employer's Address
Salary $ perEmployer's Telephone Number
If unemployed,
list last place of employment
Date of last paycheck
List the source and amount of any other income you receive
List all your dependents, their ages, and their relationship to you

ESTIMATE YOUR AVERAGE CURRENT MONTHLY EXPENSES FOR YOU AND YOUR FAMILY:

a. Home mortgage payment, rent, or lot rental for trailer: $
b. Utilities (electricity, water, gas, telephone): $
c. Food and sundries: $
d. Medical, dental, and drug expenses: $
e. Insurance (auto, life, medical, homeowners/renters): $
f. Transportation, including auto payments: $
g. Alimony or child support payments: $
h. Other expenses: $

I understand that until my fines and court costs are paid in full I have a continuing obligation to notify the Court of any changes in my financial status that may hinder my ability to satisfy the judgment or help me satisfy the judgment.

I understand that submitting false financial information to the Court constitutes the crime of tampering with a governmental record, punishable by incarceration and/or the imposition of a fine (Section 37.10, Penal Code). I swear that all the information in this application is true, correct, and complete to the best of my knowledge and belief.

Date Defendant’s Signature


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