Request to Make Payments Page 1 of 4 You must go to Court on (Court Date): at G a.m. G p.m. Courtroom: (Court, Address, Zip) Reset Date: Time: G a.m. G p.m. Review Date: Time: G a.m. G p.m. To ask the court to allow you to make payments on this case, you must: Send a copy of your completed form to the Plaintiff/Creditor or his/her lawyer, andGo to a court on the date listed above that the clerk222s office gave you.Do not agree to pay more than you can afford. At this time, the law allows you to keep at least$217.50 of your weekly paycheck. If your weekly pay is more than $217.50, the amount that can betaken (garnished) is the difference between your net weekly pay and $217.50 or 25% of your netwage, whichever is greater. You may have to pay a filing fee. Can222t afford the fee? Ask the court clerk for a paper called a Request to Postpone Filing Fees and Order (Uniform Civil Affidavit of Indigency). Or go on the internet to www.tncourts.gov or www.justiceforalltn.com to get the form. I ask the court to allow me to make payments of (amount): $ beginning (date) toward this judgment, pursuant to Tennessee Code Annotated 26-2-216. This amount will be paid (check one): Weekly Bi-weekly Monthly Your Information Full Name: Address: street address city state zip Tel. (home): (work): (cell): Birth date (mm/dd/yy): Dependents List your dependents below. Name Age Relationship Name Age Relationship State of Tennessee Court (Must Be Completed) County (Must Be Completed) Request to Make Payments (Motion and Affidavit for Installment Payments and Order) File No. (Must Be Completed) Division (Large Counties Only) Plaintiff/Creditor (Name: First, Middle, Last of person/company that filed lawsuit) Defendant/Debtor (Name: First, Middle, Last of the other person) American LegalNet, Inc. www.FormsWorkFlow.com Request to Make Payments Page 2 of 4 1. 4. 2. 5. 3. 6. Employment: If you are working now, fill out below. If not working now, check here: Employer222s name: Employer222s address and tel. #: street address city state zip tel # How much do you earn after taxes are deducted? $ each (check one): week month Other: Other Income: List any other income that you get now or expect to get. Source of Income How much do you get? Source of Income How much do you get? AFDC $ / month Unemployment $ / month Social Security $ / month Worker222s Comp. $ / month Retirement $ / month Other* $ / month Disability $ / month SSI $ / month *Explain source of Other income here.Other: Assets: List all assets that you own separately, with your spouse or with someone else: Fair Market Value Money still owed = 1.Car, truck, or other vehicle $ 2.Other car, truck, or other vehicle $ 3.House, condominium, land $ 4.Other house, condominium, land $ List all bank/financial accounts below: American LegalNet, Inc. www.FormsWorkFlow.com Request to Make Payments Page 3 of 4 Bank name Balance 5. $ 6. $ 7. Cash $ Total: $ Other: Expenses How much each month? How much each month? Rent/House Payment $ Gas $ Phone $ Child Care $ Groceries $ Court - ordered Child Support $ School Supplies $ Transportation $ Electricity $ Medical/Dental $ Clothing $ Other $ Water $ Other $ Debts: Who do you owe? How much do you owe? Who do you owe? How much do you owe? 1. $ 4. $ 2. $ 5. $ 3. $ 6. $ List any other facts you want the court to know, such as unusual medical expenses, family emergencies, etc. I declare under penalty of perjury under the laws of the State of Tennessee that: The information I have provided is true, correct, and complete. Sign here: Date: Sworn and subscribed before me this day of , 20. Deputy Clerk or Notary Public Bring the original a nd 2 copies of this form to the Court Clerk to be date stamped. Give the original to the Court Clerk. Bring a stamped envelope addressed for each plaintiff to the Court Clerk. Mail one copy to the lawyer or if there is no lawyer, mail it to the plaint iff or company that sued you. Keep one copy for yourself. American LegalNet, Inc. www.FormsWorkFlow.com Request to Make Payments Page 4 of 4 A review of this decision is set for (Date) at (Time) (Location) Certificate of Service: (How I gave this paper to the Plaintiff/Creditor) I certify that I (check one box) hand delivered or mailed by first-class mail, properly addressed, a true and correct copy of this paper to the person listed below at the address below: Name of Who You Are Giving This To (The creditor222s lawyer or the plaintiff/creditor if no lawyer) Address of the Lawyer or the Creditor (Include City, State and Zip Code) on . (Date you mailed/hand-delivered the copy) Sign Your Name IMPORTANT! Take any proof that supports your case to the hearing, including: witnesses, photos, papers, receipts, etc. The court will not accept written statements from witnesses. The person must go to court in person. If you think a witness may not want to go to court, ask the clerk for subpoena forms. Complete the subpoena as soon as possible so the sheriff can serve them before court. The court and clerks are not allowed to give you legal advice, even if you don222t have a lawyer. This form is a public record. It is not legal advice. The law may change and it is best to consult with a lawyer if possible. DO NOT FILL OUT THIS SECTION BELOW. THE JUDGE WILL FILL THIS SECTION OUT AT COURT. The court denies this Request because (judge will check all that apply): The defendant did not prove s/he has the right to make payments. The defendant did not go to the court hearing for this case. This Request is dismissed. The defendant must pay court costs of: $ The court approves this Request because the defendant proved s/he has the right to make payments. Garnishment will end, and the defendant will pay as follows: Payments of: $ , on the day of each (month, week, other): starting (date): until (date of final payment): , Payments will be made to (check one): Plaintiff or his/her lawyer Court Clerk This decision was made by (check one): The Plaintiff did not show up to court (Default) After a court hearing. By agreement of the parties. Judge222s signature: Date: American LegalNet, Inc. www.FormsWorkFlow.com