In the State Court of Chatham County, Georgia 133 Montgomery St. Suite 308 Savannah, GA 31401 fines@statecourt.org 133 Montgomery St. Suite 308 Savannah, GA 31401 fines@statecourt.org DEFENDANT'S IN PAIS REGARDING FINE PAYMENTS Date To: From: ___________ Case # ____________ Fines Collection Clerk, Judge, State Court of Chatham County , Defendant SECTION I Defendant's Statement I, the above named defendant, was sentenced in the State Court of Chatham County on misdemeanor charge(s) which include the case cited above. The financial obligation assiciated with that account, for all 0.00 case(s), is currently in arrears in the amount of $ ______________. I understand that several notices have been sent to me, specifically, notices 30 and 60 days after the non-receipt of a required payment. Further, I have made no contact with the Court or the Fines Collections office regarding this matter. Now, at least 90 days since the first payment was missed, during which I had no contact with the Court, a final notice was sent to me. I was advised that my account is being turned over to a collection agency for further action, however, the defendant hereby asks for one more opportunity to appear at the Clerk's office and address this matter. If a FINANCIAL DISABILITY is being claimed, a State Court FINANCIAL AFFADAVIT is required. I regret my earlier disregard of the notices I received and ask the Court's indulgence regarding payment of the obligation shown above. The reasons this account is deliquent status are as follows: REASON FOR NON-PAYMENT REASON FOR IGNORING NOTICES Financially unable. See attached Financial Affidavit Unable to pay, see attached sheet. I had other, higher priority requirements Just didn't respond, don't know why. Unemployed since _______________ Other as explained on the attached sheet SECTION II Collection Clerk's Input $0.00 Amount that may not be suspended (DUI)___________ Remmendation:: ________________________, Fine Clllections Clerk, State Court of Chatham County. SECTION III Order of the Court Court's Order: Concur with the Clerk's recommendation as stated. Other. So Ordered Today, _____________________ Judge, State Court of Chatham County American LegalNet, Inc. www.FormsWorkflow.com h-.DefendantsInPaisreDeliquentFines (P.1 of 3) Page 2 of 3 SUPPLEMENTAL SHEET ~ DEFENDANT'S IN PAIS RE FINE PAYMENTS DATE: _____________ CASE #______________ TO: State Court of Chatham County FROM: _______________________________, Defendant As the above named defendant, I was sentenced in the State Court of Chatham County on misdemeanor charge(s) which include the case cited above, having a total financial obligation to the Court in the amount 0.00 of $ __________. I understand that the Court has sent me at least three notices regarding this matter at 30 day intervals. Until today, I have not responded and now wish to make the following comments: I HAVE NOT COMPLIED WITH THE ORDER OF THE COURT TO PAY ALL ASSOCIATED FINANCIAL OBLIGATIONS BECAUSE I DID NOT RESPOND THE PREVIOUS NOTICES SENT BY THE COURT BECAUSE My Financial Affadavit is enclosed. DEFENDANT'S SIGNATURE / DATE h-.DefendantsInPaisreDeliquentFines (P.2 of 3) American LegalNet, Inc. www.FormsWorkflow.com American LegalNet, Inc. www.FormsWorkflow.com TOTALS Original Debt Amount Paid Current Balance -1.00 Real Estate - FM Value 0 Less Amt Owed Automobile(s) 0 Less Amt Owed -1 Net Real Estate Net Automobile NET INCOME: TOTAL INCOME: TOTAL EXPENSES: MONTHLY I N C O M E AFDC Alimony (Receiving) Unemployment Food Stamps Trust Fund Investment Dividends Claims / Settlements Disability Child Support GET Worker's Comp Social Security Pension Other Income Wages + Assistance Stocks & Bonds Retirement Account(s) Cash, Other than savings Checking Account(s) Other Assets Not Shown Total All Assets CLEAR FORM NET ASSETS (Less Debts) Date: 0.0 Other Payment MONTHLY OBLIGATIONS CONTINUED Rent / Mortgage Trailer Lot Rental Telephone Cable Other Utilities Food Car Payments Car Maintenance Car Insurance Gasoline / Fuel Child Support Beeper / Pager Medical Expenses Medical Insurance Alimony Payments Loan Payments Clothing Internet Connection Cell Phone Other Payment FOR OFFICIAL USE ONLY h-.DefendantsInPaisreDeliquentFines (P.2 of 3) DATE Total Expenses I certify this to be true and correct. Who, if anyone, assisted in completing this form? Prepared By: Other Payment Household Expenses School Water, Sewage & Garbage Pickup Gas Electric MONTHLY OBLIGATIONS OTHER ASSETS Cash in Savings Accounts Boat(s) and Other Vehicles Inheritances Legal/Insurance Settlement Real Estate Other Assets Not Listed Total Other Assets Please print the name of your employer and pay. If paid weekly MULTIPLY by 4 for total earnings per month. Monthly Pay Employer's Name & Phone: Employment Information Date Incurred Financial Affidavit for the State Court of Chatham County, Georgia Name: Address: Debt 1 Debt 2 Debt 3 Debt 4 o}a100