57th District Court Collection Form

Collection Information

STATE OF MICHIGAN 57TH DISTRICT COURT
113 Chestnut Street, Allegan, MI 49010 • 269-686-5273
PETITION AND ORDER FOR INSTALLMENT PAYMENTS/ASSIGNMENT OF WAGES

1. Case Number(s):

2. Defendant Information: *This question is required.

First Name

Last Name

Street Address

Apt/Suite/Office

City

State

Zip

Email Address

Home Phone

Work Phone

Cell Phone

Judgment/Sentence Date This question requires a valid date format of MM/DD/YYYY.

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Amount Due

3. Employment:

Employer Name/Source of Income

Employer Address

Income Received

Income Frequency

Please enter an 'other' value for this selection.

__________________________________________________________

ORDER FOR INSTALLMENT PAYMENTS
__________________________________________________________

4. Installment Payments:

Defendant asks for installment payments of

paid every

beginning on This question requires a valid date format of MM/DD/YYYY.

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5. Defendant's Signature:

Date This question requires a valid date format of MM/DD/YYYY.

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Signature (sign and type name below)

Clear

Signature of

______________________________________________________________

☐ IT IS HEREBY ORDERED that defendant may pay the fines and costs in this case in installments as follows:

$___________ on or before the ____________ of the month and $_________ every __________ of the month until paid in full, or until further Order of the Court.

____________________
Date

_____________________________________________
Judge/Magistrate

______________________________________________________________

6. Wage Assignment:(Check all that apply.)

I request the Wage Assignment not be issued unless my payments are delinquent.
I request an immediate WAGE ASSIGNMENT per pay period.

7. Enter your initials to confirm your request:

______________________________________________________________

ORDER FOR ASSIGNMENT OF WAGES
______________________________________________________________

I request an immediate WAGE ASSIGNMENT (see separate order) in this amount per pay period:

Date This question requires a valid date format of MM/DD/YYYY.

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Defendant's Signature (sign and type name below)

Clear

Signature of

____________________
Date

_____________________________________________
Judge/Magistrate