KING COUNTY DISTRICT COURT TIME PAYMENT COLLECTION APPLICATION Signal Credit Management Services (253) 620-2239 OR (800) 874-1958 ACCOUNT INFORMATION Name: ____________________________________________________________________________________________ (Last) (First) (M.I.) (Nickname) Residence Address: _________________________________________________________________________________ City, State, Zip: _____________________________________________________________________________________ Mailing Address (if different): ___________________________________________________________________________ Home Telephone #: ( _____ ) __________________________ Work Telephone #: ( _____ ) _________________________ Date of Birth: ____________________ Sex: M ______ F ______ Single ______ Married ______ Div _____ Widowed _____ Drivers License #: ________________________________________ SSN: _______________________________________ Employer or Name of Business: _________________________________________________________________________ Employer Address: ___________________________________________________________________________________ Occupation: _____________________________________ Take Home Pay: _____________________________________ Nearest Relative Name: ______________________________________ Relationship: ______________________________ Relative’s Address:____________________________________________________ Phone: ( _____ ) _________________ Contact Person Name: ______________________________________ Phone: ( _____ ) ____________________________ Contact’s Address: ___________________________________________________________________________________ SPOUSE INFORMATION Name:______________________________________________________________________________________________ (Last) (First) (M.I.) (Nickname) Residence Address (if different from above): ________________________________________________________________ City, State, Zip: _______________________________________________________ Phone: ( _____ ) _________________ Employer or Name of Business__________________________________________________________________________ Employer Address and Phone: __________________________________________________________________________ Occupation: _____________________________________________ Take Home Pay: ______________________________ American LegalNet, Inc. www.FormsWorkFlow.com TIME PAYMENT AGREEMENT Case Number: __________________________________Database: KING COUNTY DISTRICT COURT__ Name: ______________________ SCMS Acct No.: ____________ Set Up Deadline: _________________ Total Amount Owed to KCDC: $ ____________________________ (This amount includes Fine/Penalty/Probation/Costs/Fees/Assessments.) Account Set-up Fee (one time charge — if no previous KING COUNTY DISTRICT COURT account) $ ____15.00_____ Minimum Monthly Payment Amount (10% of account balance if total amount owed is less than $1,000; 5% of account balance if total amount is $1,000 or more; or $25.00, whichever is greater.) $______________ FIRST PAYMENT REQUIRED FOR ACCOUNT SET-UP: $ ______________ MONTHLY PAYMENT: $______________ If you need assistance in determining your monthly payment, call SCMS at 1-800-874-1958. TIME PAYMENT AGREEMENT In addition, Court costs will be assessed each month to the total amount owing, as follows: A. The account set-up fee of $15.00 (if applicable) and the first payment must be paid before the account will be set up by SCMS. B. If the account is in “current status” (all payments made as agreed) the monthly court cost shall be $4.75 for one case or $8.25 for multiple cases. C. If the account falls into “past due status” (any payments not made as agreed) the monthly court cost shall increase to $7.75 for one case and $11.25 for multiple cases, for every month thereafter. 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. PLEASE CIRCLE A PAYMENT DUE DATE. YOUR PAYMENT WILL BE DUE ON THIS DAY EACH MONTH. Please include your case number with all payments. 5th 10th 15th 20th 25th 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, may assess additional court costs pursuant to RCW 3.02.045, and may refer the account to a collection agency for full collection efforts. If this is a traffic infraction, the court may also assess a $52.00 failure to pay penalty, a hold may be placed on your license and the Department of Licensing in Olympia may send you a letter concerning the status of your license 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_________________________________ American LegalNet, Inc. www.FormsWorkFlow.com