Fillable Partial Payment Agreement Form printable pdf download

IN THE CIRCUIT COURT OF THE FIRST JUDICIAL COURT

IN AND FOR SANTA ROSA COUNTY, FLORIDA

STATE OF FLORIDA

CASE#:_________________________

_____________________________

Defendant

CRIMINAL / NON-CRIMINAL / TRAFFIC PARTIAL PAYMENT AGREEMENT

You, the Defendant, have elected or have been ordered by the Court to pay partial payments to the Clerk of Courts, Santa Rosa

County, Florida. You represent that you are unable to pay the fines/costs due on this case without a payment plan. You will pay the

amount owed plus an administrative fee of $25.00 (one-time fee) pursuant to this Partial Payment Agreement.

Defendant submits the following financial/contract information:

1. Mailing Address: __________________________________; City: ______________________; State: _____ ; Zip: __________

2. Home Phone: ___________________ Cell Phone/Pager: ______________________ Work Phone: ____________________

Primary Contact Number: Home Phone:

Cell Phone:

Work Phone:

3. Employer: ___________________________________________________________________________________________

4. Income: $ ______________

Weekly

Bi Weekly

Monthly 5. Email: ___________________________________

List Name and Phone Number(s) of Personal Reference:

______________________________________________________________________________________________________

Name

Phone

Alt. Phone

Relationship

The defendant agrees as follows:

1. Acceptable forms of payment are cash, money order, cashier’s check, certified check, local check, debit or credit card.

Clerk Only:

2. Defendant will pay the one-time fee of $25.00 (to be paid with first payment).

3. Defendant will pay $__________ today or defendant’s first payment of $__________ will be paid on ___________________

followed by $___________ on the

__________ of each month.

(County Probation Cases)

(Collection Dept.)

The balance of $___________ (plus partial pay fees, judgment interest, service charges and/or collection fees, if any) must be

paid in full by __________________________________ (please initial)

4. Payments may be paid before the due date and/or for more than the agreed upon amount without penalty

If you fail to comply with the payment plain pursuant to this agreement and you remain in default for five (5) calendar days from

The due date of the payment, your driving privilege may be suspended. In addition, you will be assessed additional fees and this

agreement will be null and void. I understand the above terms and obligations and I agree to comply with this Partial Payment

Agreement. The Santa Rosa County Clerk is authorized to send me, as a courtesy, automated reminder messages.

____________________________________

__________________________________

Defendant’s Signature

Date

____________________________________

__________________________________

Deputy Clerk/Notary Public

Date

Payment Options

a. You may pay by local check or money order by mail to Clerk of Courts, P.O. Box 472 Milton, FL 32572, Attn: Your Case #

b. You may pay in person by cash, local check, money order, or credit/debit card between 8:00 am and 4:30 pm*, Monday thru Friday at the Santa Rosa

County Courthouse, 6865 Caroline St. Milton, FL 32570 or South End Service Ctr., 5841 Gulf Breeze Pkwy., Gulf Breeze, FL.

c. You may pay by credit/debit card by phone during normal business hours* Please call (850)981-5570

Rev. 10/08/2015

Partial Payment Agreement Form

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