Application for Payment Plan for Court
Costs, Fines and/or Fees
(02/24/17) 337_033 A
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
APPLICATION FOR PAYMENT PLAN FOR COURT COSTS, FINES AND/OR
FEES
Answer all the questions
PERSONAL INFORMATION
Case Number: _______________
Last Name: ___________________________ First Name: _______________________ Middle Initial: ____
Date of Birth: ___________ SSN*: _____________ Sex:
Male
Female
Home Address:
Mailing Address (If different)
City: _______________________________ State: ____ Zip: ________
Home Phone: _____________ Cell Phone: _____________ Email Address: _________________________
Driver License or ID Number: ______________________________________ State of Issuance: ____
Expiration Date: ___________
Marital Status/Civil Union:
Married
Single
Widowed
Divorced
Spouse’s Name: ____________________________________________
FRIENDS OR REFERENCES
Name: _______________________________________________
Address: _____________________________________________________________ Phone: _____________
Relationship: ________________________________
Name: _______________________________________________
Address: _____________________________________________________________ Phone: _____________
Relationship: ________________________________
PAYMENT AGREEMENT
Total amount due: $ ____________________
I agree to set up an Automatic Debit to make my payment. (Please complete Page 3)
I agree to mail in my payments of: $ ____________________ on: _____________________
Pay Schedule:
Weekly
Biweekly
Monthly
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
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