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Petition For Deferred Or Installment Payment Of Fines And Cost Form. This is a Virginia form and can be use in Circuit Court Statewide.
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Tags: Petition For Deferred Or Installment Payment Of Fines And Cost, CC-1378, Virginia Statewide, Circuit Court
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
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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
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www.USCourtForms.com