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Rev 12-11 MARYSVILLE MUNICIPAL COURT, WASHINGTON TIME-PAYMENT COLLECTION APPLICATION Managed by Signal Management Services (SMS) [PHONE REDACTED] or [PHONE REDACTED] 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) (Last) (First) 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 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 By my signature below I authorize a payment of per month to be withdrawn from my account on or after the day of every month, beginning with the month of until my account is fully paid, by the following method (check one): checks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 ---PAGE BREAK--- Rev 12-11 MARYSVILLE MUNICIPAL COURT, WASHINGTON TIME-PAYMENT COLLECTION PROGRAM Managed by Signal Management Services (SMS) [PHONE REDACTED] or [PHONE REDACTED] Account Set-up Fee (if no current SMS time-payment account in this Court): $ 15.00 Minimum 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): $ PAYMENT THEREAFTER: $ Your time-payment program is subject to approval and/or modification by the Court. For assistance in determining your first payment or payments, call Signal Management Services (SMS) at [PHONE REDACTED]. The account set-up fee of $15.00 (if applicable) and the first month’s payment must be paid before the account will be set up by SMS. Court costs and interest will be assessed each month to the total amount owing, as follows: A. If your account is in “current status” (all payments made as required) the court cost shall be $4.75 for one case or $8.25 for two or more cases. B. If your account falls into “past due status” (any payment not made as required) the court cost shall increase to $7.75 for one case or $11.25 for two or more cases, for every month thereafter. C. Interest may accrue on all outstanding amounts. It is in your best interest to make payments larger than the minimum each month and/or pay the account in full early. HOWEVER, an additional or larger payment made in one month will not change the “Minimum” payment due the next month. If a payment check is dishonored, a handling fee will be assessed and other statutory fees may be assessed. Electronic payments credit/debit card) will be assessed a transaction fee, currently $3.00. PLEASE CIRCLE A PAYMENT DUE DATE. IF THE COURT ACCEPTS YOUR PLAN, YOUR PAYMENT WILL BE DUE ON THIS DAY EACH MONTH. YOU MUST INCLUDE YOUR ACCOUNT NUMBER WITH ALL PAYMENTS. 5th 10th 15th 20th 25th ALL PAYMENTS ARE TO BE SENT TO: SIGNAL MANAGEMENT SERVICES P.O. BOX 11622 TACOMA, WA 98411 YOU MUST MAKE PAYMENTS AS REQUIRED AND KEEP YOUR PERSONAL INFORMATION (SUCH AS ADDRESS, PHONE NUMBERS, EMPLOYMENT) CURRENT WITH SMS, OR THE FOLLOWING WILL OCCUR: All amounts will become immediately due. The court may re-impose suspended portions of the fine/penalty/costs, assess additional court costs, and refer the account to a collection agency for full collection efforts. For a traffic infraction, the court may also assess a failure to pay penalty, a hold may be placed on your license until all amounts are paid, and the Department of Licensing may contact you concerning the status of your license. For a criminal matter, the court may issue a bench warrant and impose a fine or cost for contempt of court. By my signature, I promise to meet the above payment requirements and other conditions; and I consent to the Court, SMS and their agents (including collection agents) contacting me by any commercially-available means including but not limited to via email, telephone, cellular phone, text message, or other wireless device, and including via automatically-dialed calls and messages, and with pre-recorded or artificial voice messages. SIGNATURE: DATE: This box is filled out by the Court and/or SMS: Court District/Division: Case Number: Name: SMS Acct No.: Account Set-Up Deadline Date: Total Amount Owed (including Fine/Penalty/Probation/Costs/Fees/Assessments): $