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2. Date*
   Date
3. Case Number(s): *

   Please list the case number(s) you wish to be considered for a payment plan. 

5. Name*
6. Date of Birth*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Payment Reminders*

    1. Yes
    2. No

    Would you like to receive text message payment reminders? 

    (Data rates may apply..) 

17. Email Address
18. How would you like to receive a response from the Court? *

    1. Email (Please be sure to provide an email address.)
    2. Postal Mail (Please be sure to provide an accurate mailing address.)
20. Please select which payment plan you are requesting. *

    1. $50.00 Minimum Payment Plan (If you selected this option, you do not need to complete the form, just click "submit.")
    2. Reduced Payment Plan (If you selected this option, complete the rest of this form.)

24. If you have selected the Reduced Payment Plan option, please provide the following information.  

26. For your household, what is your total monthly income from all source?
28. Including yourself, how many people in your household do you support?
30. I understand the court may require verification of the information provided above. I agree to immediately report any change in my financial status to the court. I certify under penalty of perjury under Washington State law that the information I have provided on this form is true and correct. (Perjury is a criminal offense RCW 9A.72.)
32. Date*
    Date
33. Signature*
37. FOR COURT USE ONLY
39. Determination of Eligibility for Reduced Payments

    1. Eligible for Reduced Payment. Amount $__________
    2. Not Eligible for Reduced Payments
41. Reviewed On:
    Reviewed On:
42. Reviewing Clerk:
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field