CASE NUMBER IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA IN THE COUNTY COURT, BREVARD COUNTY, FLORIDA DIVISION CIVIL REQUEST TO APPROVE DEFERRED PAYMENT CRIMINAL AGREEMENT OF A NON-INDIGENT PARTY JUVENILE IN A CIVIL, FAMILY OR PROBATE CASE TRAFFIC BAR CODE LABEL PLAINTIFF/PETITIONER CLOCK IN 05 - - - - XXX-XX RESPONDENT/DEFENDANT/CHILD plaintiff/petitioner respondent/defendant/child of a child 1. I, ________________________________ am the or tax-dependent adult and hereby certify that I am not indigent but I am unable to pay the court-related fees, service charges, court costs or fines imposed in this case by the date due. I agree to pay $__________ today, follow ed by $__________ on or before the 10th day of each month, commencing ______________________________ until the balance is paid in full. 2. I fully understand that if I fail to make my payment by the 10th of each month, the balance ow ed may be placed w ith a collection agency and I may incur an additional assessment of up to 40% of the amount ow ed. 3. I understand the Court must approve this deferred payment agreement. If the Court does not approve this deferred payment agreement, I must make payment w ithin 10 days 4. I understand that if the Court approves the deferral of my financial obligation, the Clerk is authorized to charge a $25.00 fee to enroll me in a deferred payment program. 5. The total due on this case is $_______________ (including the $25.00 enrollment fee). The current balance that is ow ed is $_______________. 6. I certify that my current employer is: _______________________________________________________________ Employer' s Address: ___________________________________________ ___________________________________________ Employer' s Telephone Number: ( )______________________________________ Current Salary: $_______________per ________________. I ow n, rent, or am provided board at the follow ing address:____________________________________ ______________________________________________________________________________________________________ Signature: _________________________________________ Print Name: ________________________________________ Current Address: __________________________________ Current Telephone Number: ________________________ Date: ________________________________________ DL or State ID No: _____________________________ City, State, Zip Code:___________________________ Scott Ellis, Clerk of Courts By: ________________________________________, Deputy Clerk OR NOTARY STATE OF FLORIDA, COUNTY OF BREVARD Sw orn to or affirmed and signed before me on { date} _________________________________, 200____ by { name} __________________________________________ [ ] personally know n [ ] produced identification type of identification______________________________. My commission expires: LAW 926 Rev. 12/13/2005 _____________________________________________ NOTARY PUBLIC ORIGINAL - COURT FILE American LegalNet, Inc. www.FormsWorkflow.com