KCDC _________________ Issaquah Courthouse SOUTH DIVISION TIME PAYMENT AGREEMENT Set Up Deadline:____________________ (date to be filled in by the Court) Name: __________________________________________ Case Number * ___________________ Fine/Penalty/Costs * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Account Set-up Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amount Owing **. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ __________________ 15.00 $ $ __________________ Minimum Monthly Payment Amount (usually 10% of violation) $ __________________ * See reverse for multiple case numbers and account details. ** Costs will be assessed each month in addition to the total amount owing, as follows: A. The account set-up fee of $15.00 and the first payment must be paid at the time the account is set-up. B. If the account is in “current status” (all payments made as agreed) the monthly cost shall be $4.75 per case; or $8.25 for multiple cases. C. If the account falls into “past due status” (any payment not made as agreed) the monthly cost shall increase to $7.75 per case, or $11.25 for multiple cases, every month there after. It is in your best interest to make payments larger than the minimum due each month and/or to pay this account in full early. HOWEVER, an additional or larger payment made in one month will not change the “Minimum” payment due the next month. December 05 ALL PAYMENTS ARE DUE ON THE ____________ OF THE MONTH BEGINNING ____________, 20_____. Please include your case number with all payments. ALL PAYMENTS ARE TO BE MAILED TO: SIGNAL CREDIT MANAGEMENT SERVICES P.O. BOX 1849 GIG HARBOR, WA 98335 IF YOU FAIL TO MAKE PAYMENTS AS PROMISED AND/OR FAIL TO KEEP YOUR PERSONAL INFORMATION (ADDRESS AND PHONE NUMBERS) CURRENT, THE FOLLOWING WILL OCCUR: All amounts will become immediately due. The court may re-impose suspended portions of the fine/penalty/costs, will assess additional court costs pursuant to RCW 3.02.045, and will refer the account to a collection agency. If this is a traffic infraction, the court will also assess a $48.00 failure to pay penalty and notify the Department of Licensing, and your driver’s license will be suspended until all amounts have been paid. If this is a criminal matter, the court may issue a bench warrant for contempt of court and impose a fine or cost for contempt of court. SIGNATURE _________________________________________SSN ____________________ ADDRESS ___________________________________________ PHONE CITY/STATE _________________________________________ZIP_____________________ COURT CLERK: _____________________________________ DATE ___________________ American LegalNet, Inc. www.USCourtForms.com Case # : __________________________ Total Fine/Penalty/Costs: $___________ Violation Date: ____________________ Suspended Amount, If Any: ($ __________) Violation Detail: _____________________ Failure To Respond Penalty: $ ___________ TOTAL DUE: $ ___________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Case # : _________________________ Total Fine/Penalty/Costs: $ ___________ Violation Date: ____________________ Suspended Amount, If Any: ($ __________) Violation Detail: _____________________ Failure To Respond Penalty: $ ___________ TOTAL DUE: $ ___________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Case # :__________________________ Total Fine/Penalty/Costs: $____________ Violation Date: ____________________ Suspended Amount, If Any: ($ __________) Violation Detail: _____________________ Failure To Respond Penalty: $ ___________ TOTAL DUE: $ ___________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com