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2. 
4. Time Payment Application

   In order to be considered for a Time Payment Agreement, it is mandatory that the following information be provided to the court.

6. Case Number (s)
10. First Name*
11. Last Name*
13. Address 1*
15. Address 2
17. City*
18. State*
19. Zip*
21. Phone Number*
22. Email Address*
24. Date of Birth
25. Driver's License Number
29. Employer
30. Position/Title
32. Address
34. City
35. State
36. Zip Code
40. Reference

    Please list one personal reference that can be contacted if you move or change employment

42. First Name*
43. Last Name*
45. Address*
47. City*
48. State*
49. Zip Code*
51. Plea of Nolo Contendere ( check only one)

    I, the undersigned, do hereby enter my appearance on the complaint of the offense noted above, I understand that I have a right to a jury trial and that my signature on this plea of nolo contendere (meaning "no contest") will have the same force and effect as a plea of guilty on the judgment of the Court. I do hereby plead nolo contendere to said offense as charged, waive my right to a jury trial or hearing by the Court, and agree to pay the fine and costs the judge assesses. I understand that my plea may result in a conviction appearing on either a criminal record or a driver's license record. I further Waive Discovery on this case.

    1. Plea of Nolo Contendere
52. Plea of Guilty

    I, the undersigned, do hereby enter my appearance on the complaint of the offense noted above I understand that I have a right to a jury trial. I do hereby plead guilty to the offense as charged, waive my right to a jury trial or hearing by the Court, and agree to pay the fine and costs the judge assesses. I understand that my plea may result in a conviction appearing on either a criminal record or a driver's license record. I further Waive Discovery on this case.

    1. Plea of Guilty
56. Acknowledgement - Please Read

    PLEASE READ THE FOLLOWING STATEMENTS BY SIGNING THE FORM THIS INDICATES THAT YOU HAVE READ THE STATEMENTS, UNDERSTAND,  AND AGREE TO THEM.

    I understand that failure to make scheduled payments on an extension of time to pay/ time-payment plan will result in the issuance of a warrant for my arrest. If you are unable to pay the fines and court costs as a result of this citation(s), please contact the court for alternatives to full payment. You may be required to attend a hearing to provide documentation of your financial status. I understand that I have a continuing obligation to notify the Court of any changes in my financial status that may hinder my ability to satisfy the judgment or help me satisfy the judgment.

    I promise that I will notify this Court in person or by first-class mail of any changes of my address or telephone number at the following address Wilmer Municipal Court 219 East Beltline Road Wilmer, TX 75172 within five (5) days of the change.

    I understand that if I pay any part of the fine, costs, or restitution (if applicable) on or after the 31st day after judgment was entered that I am responsible for paying a $15.00 time payment reimbursement fee per case (Article 102.030, Code of Criminal Procedure).

    I understand that submitting false financial information to the Court constitutes the crime of tampering with a governmental record, punishable by incarceration and/or the imposition of a fine (Section 37.10, Penal Code). I swear that all the information in this application is true, correct, and complete to the best of my knowledge belief.

58. Signature of Defendant*

    By signing this form you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your electronic signature is valid and binding upon you to the same force and effect as a handwritten signature.

    NOTE: Please make sure to check your spam folder for a reply from the Court Clerk. Some email communications may be directed to your spam folder by your current settings on your email account.

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60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit Submit and Print

* indicates a required field