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Get WA Snohomish County District Court Time-Payment Collection Application 2018-2024

SNOHOMISH COUNTY DISTRICT COURT WA TIME-PAYMENT COLLECTION APPLICATION Managed by Signal Management Services SMS 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 SMS at the above numbers. Name Spouse 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 Driver s License State of Issue Bank Name Sex M Single Married F Div Bank Acct Employer Name of Business or Income Source Employer Address Occupation Employer Phone 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. Bankruptcy Court City If yes provide Case Chapter Attorney if any Name and Telephone If you wish to make automatic monthly payments please fill out this section. Call or visit SMS if you need assistance be sure to have your checking account information available. SNOHOMISH COUNTY DISTRICT COURT WA TIME-PAYMENT COLLECTION APPLICATION Managed by Signal Management Services SMS 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 SMS at the above numbers. Name Spouse 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 Driver s License State of Issue Bank Name Sex M Single Married F Div Bank Acct Employer Name of Business or Income Source Employer Address Occupation Employer Phone 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. Bankruptcy Court City If yes provide Case Chapter Attorney if any Name and Telephone If you wish to make automatic monthly payments please fill out this section* Call or visit SMS 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 By my signature below I authorize a payment of per month to be withdrawn from my account on or after the day of every month beginning with the month of until my account is fully paid by the following method check one checks printed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 SMS and signed by an SMS 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 SMS Bank Routing and Name Bank Address City State Zip SIGN AND DATE YOUR APPLICATION Signature Date Rev 12-11 This box is filled out by the Court and/or SMS Case Number Court District/Division SMS Acct No* Account Set-Up Deadline Date Total Amount Owed including Fine/Penalty/Probation/Costs/Fees/Assessments Minimum Monthly Payment Amount if total amount owed is under 1 000 the greater of 10 of the account balance or 25 if total amount is 1 000 or more 5 of account balance FIRST PAYMENT REQUIRED FOR ACCOUNT SET-UP MONTHLY PAYMENT THEREAFTER 15.

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