Request For Payment of Parking Penalty/Fee Deposit
Repspondant Name:______________________________________
Citation Number of License Plate Number:___________________________________
Address:_______________________________________________________________________
City:___________________________________State:_______________ZIP:_____________
Please Complete the Following
| 1.Employment:
|
_____ Employed
_____Full-time
_____Part-time
|
| _____ Unemployed
|
| _____ Disabled
|
| _____ Student
|
| _____ Homemaker
|
| _____ Military
|
| _____ Other
|
| 3. Persons Supported:
|
| _____ Self
|
| _____ Spouse
|
| _____ Children(# of)_____
|
| _____ Other ___________
|
| TOTAL_____
|
| 2. Supported By:
|
| _____ Self
|
| _____ Spouse
|
| _____ Parents
|
| _____ Welfare
|
| _____ S.S.I.
|
| _____ A.F.D.C
|
| _____ Unemployed
|
_____ Other
_________________
|
4. Your NET income (take home pay, welfare, etc.): $_________ every ________days.
5. If unemployed: Months of unemployment __________ Occupation: ___________
| 6. Asset (value)
|
|---|
| $__________ Motor Vehicle(s)
|
| $__________ Home
|
| $__________ Property
|
| $__________ Savings Account(s)
|
| $__________ Checking Account(s)
|
| $__________ Cash on Hand
|
| $__________ All Other
|
| TOTAL ASSETS $_____________ |
| 7. Monthly Expenses
|
|---|
| $__________ Rent/Mortgage
|
| $__________ Utilities
|
| $__________ Loans/Credit Cards
|
| $__________ Food/Clothing
|
| $__________ Transportation
|
| $__________ Medical/Dental
|
| $__________ All Other
|
| TOTAL EXPENSES $___________ |
8. If a fine is imposed, how much could you afford to pay each month? $______________
Respondent Signature:_____________________________________ Date:_______________
Office use only
Payment Plan: _____ Granted........Denied______
Signature:_____________________________ Date:__________________