Request To Make Payments Form - Tennessee
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1
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4Court
County
(Must Be Completed)
(Must Be Completed)
State of Tennessee
Select One
Anderson
File No. __________________
Request to Make Payments
(Must Be Completed)
(Motion and Affidavit for Installment Payments
Division __________________
and Order)
(Large Counties Only)
Plaintiff/Creditor ________________________________________________________
(Name: First, Middle, Last of person/company that filed lawsuit)
Defendant/Debtor _______________________________________________________
(Name: First, Middle, Last of the other person)
You must go to Court on (Court Date): _______________________ at_______
G a.m. G p.m.
Courtroom: ________________________________________________________________
(Court, Address, Zip)
Reset Date:
Time:
_______________________________
___________________
G a.m. G p.m.
Review Date: __________________________
Time: _________________
G a.m. G p.m.
To ask the court to allow you to make payments on this case, you must:
•
Send a copy of your completed form to the Plaintiff/Creditor or his/her lawyer, and
•
Go to a court on the date listed above that the clerk’s office gave you.
•
Do not agree to pay more than you can afford. At this time, the law allows you to keep at least
$217.50 of your weekly paycheck. If your weekly pay is more than $217.50, the amount that can be
taken (garnished) is the difference between your net weekly pay and $217.50 or 25% of your net
wage, whichever is greater.
You may have to pay a filing fee. Can’t afford the fee? Ask the court clerk for a paper called a
Request to Postpone Filing Fees and Order (Uniform Civil Affidavit of Indigency). Or go on the
internet to
or
to get the form.
I ask the court to allow me to make payments of (amount): $
beginning
___________________ (date) toward this judgment, pursuant to Tennessee Code Annotated 26-2-216.
Weekly
Monthly
This amount will be paid (check one):
Bi-weekly
Your Information
Full Name:
Address:
street address
city
state
zip
Tel. (home):
(work):
(cell):
Birth date (mm/dd/yy):
December 2012
Request to Make Payments
Page 1 of 4
Approved by the Tennessee Supreme Court
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