PETITION FOR DEFERRED OR INSTALLMENT PAYMENT OF FINE AND COSTS CASE NO. VIRGINIA: In the Circuit Court COMMONWEALTH OF VIRGINIA CITY/COUNTY OF VS. , Defendant Social Security Number of Defendant: Address of Defendant: Telephone Number of Defendant: I respectfully ask the Court to allow me to pay my fine and costs in deferred or installment payments. In support of my Petition, the following financial information is provided: The information provided this Court on Defendant's Financial Statement, Form DC-333, is unchanged; OR New information is provided this Court in this Petition: Employer (s) Occupation Defendant Spouse Number of Dependents Defendant Spouse Household Net Income: Take-Home Pay (after taxes, etc.) Other Income Sources (specify) Income Contribution of Dependents TOTAL NET INCOME (A) = $ $ $ S S $ Assets: Bank Accounts/Cash on Hand Other Assets (specify) TOTAL ASSETS (B) = $ S Debts Owed: Car, Housing, Credit Card, Loan, Etc. TOTAL DEBTS (C) = $ $ $ S $ S $ TOTAL DISPOSABLE INCOME (A+B-C) $ THIS STATEMENT IS MADE UNDER OATH; ANY FALSE STATEMENT OF A MATERIAL FACT TO ANY QUESTIONS CONTAINED HEREIN SHALL CONSTITUTE PERJURY UNDER THE PROVISIONS OF VA. CODE SECTION 18.2-434. THE MAXIMUM PENALTY FOR PERJURY IS CONFINEMENT IN THE STATE PENITENTIARY FOR A PERIOD OF TEN YEARS. I hereby state that the above information is correct to the best of my knowledge. , Defendant Sworn and signed before me this day of , , Clerk/Deputy Clerk A. Defendant's Petition: B. Payment Type Approved: Accepted Deferred Installment FOR COURT USE ONLY Rejected OR Due Date Beginning Final Payment Payment WEEKLY/MONTHLY/OTHER C. Date Due back in Court for Nonpayment: D. Total Amount Due: Date: , Clerk/Deputy Clerk FORM CC-1378 (PAGE ONE OF TWO) 11/00 PDF American LegalNet, Inc. www.USCourtForms.com EXCEPTIONAL EXPENSES: Medical Expenses Court-ordered support payments Child Care payments Approximate indebtedness to other persons TOTAL EXCEPTIONAL EXPENSES {D} = $ $ $ $ $ $ {A} + {B} - {C} - {D} = {E} AVAILABLE FUNDS OF DEFENDANT {E} {D} {E} I understand that the following provisions apply if the Court grants my Petition: (1) If I am placed on supervised probation or allowed to participate in a community service work program, an installment payment schedule will be monitored by my probation officer or case worker; payments will be made to the clerk of this court; and I will keep the officer informed of any change of my residence address. (2) If I am not placed on probation or enrolled in a community service work program, payments will be paid to the clerk of this Court. (3) Violation of the Court's Order for Deferred or Installment Payment may be punished by: (a) revocation of any suspended sentence or probation; and/or (b) an additional jail sentence of up to 60 days or fine of up to $500; and/or (c) suspension of my driver's license until all fines and costs are paid; and/or (d) suspension of all motor vehicle registrations and license plates held in my name, if my driver's license is suspended or revoked; and/or (e) any unpaid amounts owed collected as an unpaid judgment garnishment, levy, etc. THIS STATEMENT IS MADE UNDER OATH; ANY FALSE STATEMENT OF A MATERIAL FACT TO ANY QUESTIONS CONTAINED HEREIN SHALL CONSTITUTE PERJURY UNDER THE PROVISIONS OF SECTION 18.2-434 OF THE CODE OF VIRGINIA. THE MAXIMUM PENALTY FOR PERJURY IS CONFINEMENT IN THE PENITENTIARY FOR A PERIOD OF TEN YEARS. I hereby state that the above information is correct to the best of my knowledge. I acknowledge receipt of a copy of my Petition and agree to accept service of the Court's Order by first class mail to my address of record. SIGNATURE OF DEFENDANT STREET ADDRESS OF DEFENDANT SOCIAL SECURITY NUMBER OF DEFENDANT TELEPHONE NUMBER OF DEFENDANT Sworn and signed before me this day of , CLERK/DEPUTY CLERK Deferred payment plan petition accepted? FOR COURT USE ONLY No Yes Frequency of payment: (circle one) weekly monthly Other (describe) Amount of payment: $ Date: Signed: FORM CC-1378 (PAGE TWO OF TWO) 11/00 PDF American LegalNet, Inc. www.USCourtForms.com