Declaration of (Name): First Name Last Name Docket Number(s) The docket number is not the same as the infraction number listed on your ticket. You must wait to submit this form until the Office of Administrative Hearings has your case and assigns you a docket number. If you submit this form without a docket number, it will not be processed. Please answer all of the questions. Payment Plan 1. What dollar amount are you requesting to pay in each installment? 2. How frequently do you want to make payments? Weekly Monthly Other… Enter other… 3. What is your monthly household income? 4. Do any other members of your household (i.e., roommate(s) or other adults living with you) help pay for household expenses (rent/mortgage, power, food, etc.)? No Yes If yes, how much do these household members contribute per month? 5. Why do you need the payment plan at the amount and frequency that you are requesting? 6. After all your required monthly living expenses are paid, how much extra money do you have per month? 7. Please list your monthly required living expenses, such as, but not limited to, rent, utilities, childcare, insurance, etc. Additional Information - PDF Only Upload One file only.100 MB limit.Allowed types: pdf. I have attached (number) of pages: I agree and declare under penalty of perjury under the laws of the state of Washington that the facts I have provided on this form (and any attachments) are true. Submit Leave this field blank
