Application for Payment Extension


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  DALLAS COUNTY DISTRICT COURTS 
  APPLICATION OF EXTENSION OF TIME FOR PAYMENT 
 
HOW MANY FELONY CASES DO YOU HAVE? (CUANTOS CASOS DE FELONIA TIENES?) 
PERSONAL 
 
NAME  ____________________________________________________________________________________________________________ 
(Nombre)     Last (Apellido)                                             First (Nombre)                                                  Middle (Segundo Nombre) 
 
ADDRESS _________________________________________________________________________________________________________ 
(Direccion)  Number (Numero)           Street (Calle)                      City (Ciudad)                        State (Estado)               Zip (Codigo Postal) 
 
HOUSE OR APT.?  ___________________            (If apt. please put apt. #) __________________________ 
(Casa or Apt.?)                                                           (Apt. Numero) 
 
PHONE (TELEFONO) _______________________________________________________________________________________________ 
                                        Home (Casa)                                                 Cell (Celular)                                      Work (Trabajo)  
 
IF NO PHONE, WHERE CAN YOU BE REACHED? (Segundo Telefono)    (______) ________________________ 
 
E-MAIL ADDRESS (Correo Electronico) ________________________________________________________________________________ 
 
DATE OF BIRTH _____________________                   DRIVERS LICENSE # _______________              STATE ________ 
(Fecha De Nacimiento)                                                      (Numer De Licencia para Manejar)                           (Estado) 
 
SOCIAL SECURITY #  (Seguro Social)  ______________________________  GENDER (Genero) _______  RACE (Raza) ______________  
 
HEIGHT (Altura) ________  WEIGHT (Peso) ________  EYE COLOR (Color de ojos) ________  HAIR COLOR (Color de pelo) _________ 
 
LIST THE NAMES AND PHONE NUMBERS OF TWO (2) PERSONAL REFERENCES 
(Liste el nombre y telefono de dos personas referencia) 
 
___________________________________  (_____) ______________________  ______________________________ 
Name (Nombre)                                                                      Phone (Telefono)                                  Relationship (Pariente) 
 
___________________________________  (_____) ______________________  ______________________________ 
Name (Nombre)                                                                      Phone (Telefono)                                  Relationship (Pariente) 
 
ASSETS (FONDOS) 
 
EMPLOYER __________________________________________________  (_____) ____________________    (______________________) 
(Trabajo)                                        Name (Nombre)                                                       Phone (Telefono)                          How Long? (Anos) 
                      
                      _______________________________________________________________________________________________________ 
                      Address (Direccion)  Number (Numero)  Street (Calle)                      City (Ciudad)            State (Estado)  Zip (Codigo Postal) 
 
SALARY: $ _________________     HOURLY WAGE: $ _________________     TAKE HOME MONTHLY PAY:  $ _________________ 
(Salario)                                              (Salario Por Hora)                                             (Salario Mensual) 
 
PLEASE CHECK ANY OTHER SOURCES OF INCOME YOU RECEIVE AND THE AMOUNT(S): 
 
  Child Support $________/Month       Disability $________/Month      Retirement $________/Month      Soc. Sec. $________/Month 
     (Mantenimiento de nino)                        (Incapacidad por mes)                    (Retiro por mes)                                (Seg. Soc. por mes) 
  Unemployment $________/Month     Welfare/Medicaid $________/Month      Other $________/Month 
      (Desempleo por mes)                                                                                                  (Otro por mes) 
 
BANK ACCOUNTS        Checking        at:  ____________________________________________     Balance: $ ______________________ 
(Cuenta Bancarias)               (Cheques)    (En)    
                                           Savings         at:  ____________________________________________      Balance: $______________________ 
                                               (Ahorros)    (En)                                          
 
OBLIGATIONS (OBLIGACIONES) 
 
LIST ALL YOUR CREDITORS (MORTGAGE COMPANIES, BANKS, CREDIT CARD ACCOUNTS, FINANCE 
COMPANIES, RENT-TO-OWN COMPANIES) 
ENUMERE  A TODAS SUS ACREEDORES (HIPOTECA, BANCOS, TARJETAS DE CRIDITO, COMPANIAS DE FINANZA EST.) 
 
________________________________________________________________________________________________ 
Company Name (Nombre de la Compania)                         Balance Owing  (Balance Adeudado)                         Payment Amount  (Cantidad) 
 
________________________________________________________________________________________________ 
Company Name (Nombre de la Compania)                         Balance Owing  (Balance Adeudado)                         Payment Amount  (Cantidad) 
 
________________________________________________________________________________________________ 
Company Name (Nombre de la Compania)                         Balance Owing  (Balance Adeudado)                         Payment Amount  (Cantidad) 
 
________________________________________________________________________________________________ 
Company Name (Nombre de la Compania)                         Balance Owing  (Balance Adeudado)                         Payment Amount  (Cantidad) 
 
 
MONTHLY EXPENSES (GASTOS MENSUALES) 
 
Rent $______________   Utilities $______________    Phone $______________    Food $______________    Child Care $______________ 
(Renta)                              (Utilidades)                            (Telefono)                            (Comida)                            (Cuidado de Ninos) 
 
Child Support $________________    Vehicle Payment $________________    Insurance $________________    Other $________________ 
(Mantenimiento de nino)                     (Pago de Vehiculo)                                   (Aseguramiento)                            (Otro) 
 
LANDLORD  ______________________________________________________________________________________________________ 
(Casero)              Name (Nombre)                                      Address (Direccion)                                                  Phone (Telefono) 
 
 
 
ACKOWLEDGEMENT AND DECLARATION  
(DECLARACIONES Y JURAMENTO) 
 
 Under penalty of perjury I hereby certify the foregoing as being a complete and accurate statement of my current financial condition.  
I authorize the District Clerk’s Office of Dallas County, their employees or agents to conduct a complete and thorough investigation of my 
statement.  I understand this investigation could include direct verifications of all information given and the obtaining of reports from credit 
reporting agencies.  It is with this understanding and acknowledgement that I formally request an extension of time for payment of fines, court 
costs, and court appointed attorney fees if applicable. 
 
 Bajo pena de perjurio yo declaro que la siguimente es un reflejo claro de mis condiciones economicas al presente.  Yo autorizo a 
oficina District Clerk’s De Dallas, sus empleados o agentes a conducir una investigacion completa de esta declaracion.  Yo entiendo que esta 
investigacion puede incluir verificaion directa de toda la informacion proveida y obtener reportes de agencia que reportan credito.  Es con este 
entendimiento que yo fomalmente peticion una extencion de tiempo para pagar mis multa y costos de corte debido ahora al Condado de Dallas. 
 
 
Sworn and Subscribed to this ______________ day of _______________________________ 20___________, by defendant. 
(Jurado Y Suscrito Ante Mi hoy Dia)                                      (De)                                                                                                                        (Por el acusado.) 
 
 
 
___________________________________________________________________________ 
                                                           Defendant Signature 
                                                              (Firma De Acusado)