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INSTRUCTIONS TO DEFENDANT: Thoroughly and legibly complete this Defendant Financial Statement and Affidavit. Do not leave any blanks. If an item does not pertain to you, fill in “N/A” for not applicable. WARNING: It is a felony to intentionally submit false information to a court. The maximum penalty is a $150,000 fine and/or 1-½ years in prison.
Please note: If you have NOT entered a plea of responsible or having been found responsible on the civil case number listed below, by requesting this payment plan, you are hereby pleading responsible to your civil traffic charge(s), and the court will impose any fine and fees associated with each civil traffic charge(s).