Payment Plan Application Financial Affidavit

Fields marked * are required
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If applying for the Driver’s License Reinstatement Payment Plan please use this form

Personal Information

Show SSN

Mailing Address

Contact Information

One phone number is required

Employer/Income Information

List any other income (Examples: Self Employed, Social Security or Unemployment or Retirement benefits)

Obligations

Vehicle Info

Contact Option

BY SUBMITTING THIS FINANCIAL AFFIDAVIT YOU ARE CERTIFYING UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE ABOVE ARE TRUE AND CORRECT.

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