IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT IN AND FOR BAY COUNTY, FLORIDA CASE NO.: Plaintiff / Petitioner vs Defendant / Respondent PARTIAL PAYMENT AGREEMENT PURSUANT TO SECTION 28.246, FLORIDA STATUTES Pursuant to Section 28.246, Florida Statutes, I acknowledge that I have filed my financial affidavit and I have been determined to be indigent and unable to make payment in full. I hereby request the establishment of the following Partial Payment Agreement with Bill Kinsaul, Clerk of Court, and I agree to pay a non-refundable fee of $25.00, which is due and payable upon execution of this agreement. I will be obligated to pay court-related fees, charges, and costs in the amount of $ plus any additional court-related fees, charges, and costs that may arise on this case. I agree to pay the minimum of $ , monthly beginning and continuing until paid in full. All payments will be in cash (in person only), money order, cashier’s check, or credit card. I certify that I have been open and honest in entering into this payment plan. I am satisfied with this payment plan, and intend to be bound by it. I understand that failure to comply with this agreement may result in collection enforcement as provided by law. Personal Information: (Please Print) 1. 2. 3. Name: Date of Birth: Address: 4. 5. 6. 7. Telephone Number: Driver’s License No.: Business Address: Business Telephone Number: I understand the above terms and obligations and I agree to comply with this Partial Payment Agreement. Signature: Date: You may pay in person or by mail at the following location: Bay County Courthouse P.O. Box 2269 300 East 4th Street Panama City, FL 32401 STATE OF COUNTY OF Sworn to or affirmed and signed before me on by . Notary Public or Deputy Clerk Print, type, or stamp commission Personally known Produced Identification Type of identification produced American LegalNet, Inc. www.FormsWorkflow.com