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Request for 30 Day Pay Extension

2. In the Midlothian Municipal Court, City of Midlothian, Ellis County, Texas
4. State of Texas VS
6. First Name*
7. Last Name*
9. Cause/Citation Number:*
10. Offense: *
12. Mailing Address*
13. City*
15. State*
16. Zip*
17. Phone Number *
19. Email*
20. Submit Picture of Identification Card*
22. I, the above named Defendant do hereby enter my plea of NO CONTEST and waive my right to jury trial. I understand I have a right to a jury trial and my signature of this plea of nolo contendere (meaning “no contest”) will have the same force and effect as a plea of guilty of the judgment of the court. I understand my plea may result in a conviction appearing on either a criminal record or a driver’s license record. I knowledge and understand the provisions of this order and presented and agrees that he/she has the ability to fully comply. If any portion of the fine and costs is paid on or after the 31st day after the date of judgment, the Defendant shall pay an additional fee as required by Sec. 133.103 L.G.
24. To find out the amount of your Citation click the below link
    Citation Amount
26. The amount of *
27. Due on OR before 30 days from submitting date*
    Due on OR before 30 days from submitting date
29. If defendant is unable to pay by the due date, defendant will be expected to pay a minimum of $100 down and submit a request for an installment agreement. Defendant is ORDERED to notify the Court of any changes of address or financial situation that may hinder his/her ability to satisfy the judgment/order. Furthermore, I, the Defendant in the above numbered and entitled cause, do hereby acknowledge that I am hereby entering my plea and have not requested, and hereby waive any discovery pursuant Article 29.14 CCP.
    ADMONISHMENT AS TO FINANCIAL CHARGES All defendants unable to pay the entire fine and courts costs when sentenced, are required to carefully read and acknowledge the following: I, the undersigned, acknowledge that until my fines and court costs are paid in full, I agree to notify the court of any changes to my personal financial situation that will likely interfere with my ability to pay the fine and court costs in the manner ordered by the Judge. It is my responsibility to keep the court informed of my ability to pay the fine and court costs. It is my responsibility to keep the court informed in the event of financial hardship. If you are assessed fines and court costs as a result of this citation and you are unable to pay, bring this to the attention of the judge. For more information, contact the court or an attorney.
31. I acknowledge that all of the information entered above is true and correct. I agree that the name below will be electronic representation of my signature for all purposes when placed on my document, including legally binding contracts - just the same as pen and paper signature or initial. *
32. Date*
    Date
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34. 1. Receive an email copy of this form.
35. Email address

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36. Submit Submit and Print

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