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:__________________