NAME: ____________________________________________________________________ DEFERRED PAYMENT PLAN/AGREEMENT $________________________ to be received in the Dane County Clerk of Court's Office, no later than 4:30 p.m. on or before the _____________ of every month. First Payment Due:_______________. My initial payment is $ _________________. Defendant to pay $_________________ per month commencing __________________for the first _______________ months and then $ ______________ per month thereafter until paid in full. I agree to pay the Court ordered sums listed below as detailed under the DEFERRED PAYMENT PLAN/AGREEMENT. I further agree to notify the Clerk of Court's Office at 267-1514 of any change in address or phone within ten (10) days of the change. I have been given a Policy Statement regarding my payments and possible consequences for failure to pay. I understand my responsibilities to the Clerk of Court's Office for the duration of this deferred payment plan/agreement. COURT COLLECTIONS CLERK/DATE DEFENDANT/DATE CASE # __________________ - TOTAL AMOUNT DUE: _____________________________ CASE # __________________ - TOTAL AMOUNT DUE: __________________________________ CASE # _________________ - TOTAL AMOUNT DUE: __________________________________ CASE # _________________ - TOTAL AMOUNT DUE: __________________________________ TOTAL AMOUNT DUE: Less Initial Payment: $___________________ $___________________ BALANCE DUE: $___________________ American LegalNet, Inc. www.USCourtForms.com