Application for Payment Plan for Court Costs, Fines and/or Fees
(02/24/17) 337_033 B
I agree to make my payment by using the Pay by Phone service with a debit or credit card.
Payment amount: $ ____________________ (See instruction on Page 4)
OBLIGATIONS
I UNDERSTAND IF MY FINES AND FEES BECOME DELINQUENT THAT THERE WILL BE A
LATE FEE ASSESSED.
The late fees are the following:
Over 30 days delinquent: 5%
Over 60 days delinquent: 10%
Over 90 days delinquent: 15%
After 90 days, I further understand that outstanding debt will be sent to a collection agency and an additional 30%
collection fee will be assessed. I also understand that any outstanding debt is subject to tax intercept from the
Office of the State Comptroller on the behalf of the Clerk of the Circuit Court.
ACKNOWLEDGEMENT AND DECLARATION
I agree that the Clerk of the Circuit Court (CCC) or any representative may contact me by telephone at any
telephone number associated with my account, including cellular telephone numbers, which could result in charges
to me. The CCC may also contact me by sending text messages or e-mails, using any e-mail address I provide to
the CCC. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic
dialing device, as applicable.
By signing this application, I acknowledge and agree that I have read and fully understand its terms and conditions
and agree to be bound by the terms and conditions. I am signing the application knowingly and voluntarily. It is
with this understanding and knowledge that I formally request payment arrangements for payment of the fines/fees
and court costs that are now due and payable.
* Any sensitive information will be maintained by the Clerk of the Circuit Court in a secure location.
Dated: ___________
Signature of Customer
INTERNAL OFFICE ONLY
A
d
cknowledgement and
eclaration
Any information collected on this application is for the intended use of the Clerk of the Circuit Court for collection
purposes. Any misuse of this information is a violation of Clerk of the Circuit Court ethical policy.
Processed by: _________________________________
Date: _____________
Entered by: __________________________________
Date: _____________
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
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