Defendant Financial Statement and Affidavit

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INSTRUCTIONS TO DEFENDANT: Thoroughly and legibly complete this Defendant Financial Statement and Affidavit. Do not leave any blanks. If an item does not pertain to you, fill in “N/A” for not applicable. WARNING: It is a felony to intentionally submit false information to a court. The maximum penalty is a $150,000 fine and/or 1-½ years in prison.

Please note: If you have NOT entered a plea of responsible or having been found responsible on the civil case number listed below, by requesting this payment plan, you are hereby pleading responsible to your civil traffic charge(s), and the court will impose any fine and fees associated with each civil traffic charge(s).

Employed?
Monthly Income
$
$
$
$
$
$
Expenses
$
$
$
$
$
$
Accounts
$
$
$
$
$
Assets
$
$
Note: The minimum payment plan amount is $50.00.
$

I swear, under penalty of perjury that all statements and information contained herein are true and complete. I authorize the City of Chandler to verify any information contained herein with any credit bureau or investigative agency or any other source. I agree to abide by the terms set forth in a deferred payment agreement. In the event I do not comply with the terms and payments are not paid by the due date, I understand that the Court will demand the balance due and payable immediately and may issue an order to appear in Court to explain my failure to comply. I understand that if any of my charges are criminal and I fail to appear, a warrant may be issued for my arrest and a warrant fee of $125.00 may be added. I also understand that for civil traffic delinquencies, a $50.00 fee will be added to each civil charge and a default notification will be sent to the Arizona Motor Vehicle Department which will result in the suspension of my driving privileges. I understand that the court may also notify the Department of Revenue of my outstanding and delinquent balance due, to attach my tax refunds and take any legally appropriate collection action against me, my income, or my property. I understand the court may refer my outstanding balance to a collection agency and the collection agency fee will be added to my balance due.

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