Lower Kittitascounty District Court, Washington Time-Payment Collection Application Page 2
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3LOWER KITTITASCOUNTY DISTRICT COURT, WASHINGTON
TIME-PAYMENT COLLECTION APPLICATION
Managed by Signal Credit Management Services (SCMS)
253-620-2239 or 800-874-1958
You must provide the following information to be considered for the Court’s time-payment collection program. If you
have questions, you may contact SCMS at the above numbers.
Name:
Spouse:
(Last)
(First)
(M.I.)
(Last)
(First)
(M.I.)
Residence Address:
City, State, Zip:
Mailing Address (if different):
Cell Telephone #: (
)
Home Telephone #: (
)
Email Address:
Social Security No:
; Date of Birth:
; Sex: M
F
Driver’s License #:
State of Issue:
; Single
, Married
, Div
Bank Name:
Bank Acc’t #:
Employer, Name of Business, or Income Source:
Employer Address:
Employer Phone:
Occupation:
Take-Home Pay (and pay period):
Contact Person Name:
Contact Phone: (
)
Contact’s Address:
Are you currently subject to any bankruptcy proceeding (check one): No
, Yes
.
If yes, provide:
Bankruptcy Court (City):
, Case #:
, Chapter:
Attorney (if any) Name and Telephone:
If you wish to make automatic monthly payments, please fill out this section. Call or visit SCMC if you need assistance
(be sure to have your checking account information available).
By my signature below I authorize a payment of $
per month to be withdrawn from my account on or
after the
day of every month, beginning with the month of
, until my
account is fully paid, by the following method (check one):
(
) checks printed by SCMS and signed by an SCMS representative on my behalf
(the checks will be numbered sequentially beginning with the number:
)
(
) post-dated paper checks signed by the account holder, which I will supply to SCMS
Bank Routing # and Name:
Bank Address (City, State, Zip):
SIGN AND DATE YOUR APPLICATION:
Signature
Date
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