MAKE CHECKS PAYABLE TO: ________________________________________ COURT MAILING ADDRESS: PHYSICAL ADDRESS: PHONE: NAME: ADDRESS: CITY/STATE/ZIP: PHONE: CASE #: PAY $ BEGINNING ON: CASE #: PAY $ BEGINNING ON: CASE #: PAY $ BEGINNING ON: TOTAL OWED: PER MONTH BY THE 15th OF EACH MONTH TOTAL OWED: PER MONTH BY THE 15th OF EACH MONTH TOTAL OWED: PER MONTH BY THE 15th OF EACH MONTH FAX: I promise to pay my penalties as above scheduled. I understand that failure to pay as scheduled may result in (1) a delinquency charge added to my payment account, (2) suspension of my driver's license, (3) a warrant issued for my arrest, and (4) the balance owing becoming immediately due in full and referred to a collection agency (RCW 19.61.500). I also understand that, if the court refers my account to a collection agency, the balance due may be reported to a credit bureau and that I will be required to pay the additional costs of collection. INCLUDE YOUR CASE NUMBER ON ALL CORRESPONDENCE. DEFENDANT'S SIGNATURE: DATE: CLERK'S INITIALS: Payment Agreement (PAYAGR) - Page 1 of 1 CrRLJ 07.0700 - (12/2000) 2001 © American LegalNet, Inc.