Petition For Deferred Or Installment Payment Of Fine And Costs Form - Virginia, County Of Arlington
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2PETITION FOR DEFERRED OR INSTALLMENT PAYMENT OF FINE AND COSTS
VIRGINIA: In the Circuit Court for the County of Arlington, Virginia
COMMONWEALTH OF VIRGINIA
VS.
_______________________________________, Defendant
CASE #_________________
Social Security Number___________________
Telephone Number of Defendant _____________________
Address of Defendant________________________________________________________________
I respectfully ask the Court to allow me to pay my fine, costs and restitution (if any) in deferred or installment
payments. In support of my Petition, the following financial information is provided.
EMPLOYER
OCCUPATION
Defendant _________________________________ ______________________________
____________________________________
Spouse ___________________________________ ______________________________
____________________________________
Number of Dependants _________________
Household Net Income
Defendant
Spouse
Monthly Take Home Pay (after taxes)
+ $_____________
$_______________
Other Income Sources
$_____________
$_______________
Assets:
Bank Name
___________________________________________
Bank Accounts/Cash on Hand
+ $_____________
$__________________
Monthly Bills:
Car Payment:
- $_________________
Rent/Mortgage:
- $_________________
Credit Cards:
- $_________________
Loans:
- $_________________
Medical Expenses:
- $_________________
Court Ordered Support:
- $_________________
Child Care Payments:
- $_________________
Other (groceries, cell phone, water…):
- $_________________
Total Monthly Bills: $_____________________
Disposable Income: $__________________
I understand that the following provisions apply if the court grants my petition:
Clerk’s Office Policy: $100.00 minimum monthly payment unless further ordered by the
Court
1) If I am placed on supervised probation or allowed to participate in a community service work program, an
installment payment schedule will be monitored by my Probation Officer; payments will be made to the
Clerk of this Court; and I will keep the officer informed of any change of my residence address.
2) If I am not placed on probation or enrolled in a community service work program, payments will be paid to
the Clerk of this Court.
3) Violation of this Court’s Order for Deferred or Installment Payment may be punished by:
a) Revocation of any suspended sentence or probation
b) An additional jail sentence of up to 60 days or fine of up to $500
c) Suspension of my driver’s license until all fines and costs are paid
d) Suspension of all motor vehicle registrations and license plates held in my name, if my driver’s
license is suspended or revoked
e) Any unpaid amounts owed collected as an unpaid judgment garnishment, levy, etc.
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