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Form Section 1
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Payment Plans are considered on a case by case basis.  Payment plan length is determined by examination of the applicant’s monthly household income, monthly household general living expenses, and individual circumstances determined at the time of the evaluation interview.

To apply for a payment plan, please complete the initial FINANCIAL EVALUATION APPLICATION form (Click “NEXT” at the bottom of the screen to access the application). Please complete the entire form to the best of your abilities. At the end of the form, carefully read each statement, check the corresponding box to agree, and sign to finalize your application.

  • Documentation of income** is required at time of application. Please electronically attach copies of documentation indicating the source and amount of monthly income.
  •  For significantly extended payment plans, documentation of expenses (copies of monthly bills) may be required after financial evaluation application has been reviewed by staff.
  • Upon receipt of the completed application and documentation, the financial circumstances will be evaluated and staff will contact you to finalize the arrangements.
  • This application process is only for city issued invoices. If you are seeking information regarding a parking citation, please call 916-808-8500. If you are seeking information regarding a utility bill, please call 916-808-5454.
  • To finalize any payment plan, there must be a City invoice issued for services rendered.
  • It is important that you list a telephone number where you can be reached between 8:00 A.M. and 4:30 P.M., Monday through Friday.

(** Documentation indicating source of income could be: a copy of a recent paycheck stub, or social security payment, a copy of a form listing your AFDC, GA, or SSI benefits, etc.)

Form Section 2
Applicant
Birth Date
Residence Address
Is the mailing address different from the residential address?
Mailing Address

Employer Information

Employer Address
Do you have a Spouse/Significant other?
Spouse/Significant other
Spouse/Significant other's Employer address
Dependent Children Living with You

Add more

Reference - Not Living with You

Name of Friend/Relative
Address of Friend/Relative
Bank Account Type

Income Source

Applicant's

Additional source of income
Paid How?
Documentation of income* is required at time of application. Please electronically attach copies of documentation indicating the source and amount of monthly income. * Documentation indicating source of income could be: a copy of a recent paycheck stub, or social security payment, a copy of a form listing your AFDC, GA, or SSI benefits, etc.)

You have not uploaded a file. Please upload a file to continue.

Spouse/Other's

Additional source of income
Paid How?

Household Expenses (Monthly)

Utilities

Utility Total

Creditors (List all outstanding debt)

Vehicle Assets

Authorization to Release Information

I / We hereby authorize the City of Sacramento Revenue Division and its duly authorized representatives to contact any employer,bank, savings and loan, credit union, creditor, insurance company, attorney at law, or governmental agency regarding my / ourfinancial condition; and I / We further authorize such institution, individual, partnership, corporation, or agency so contacted torelease any or all information requested regarding my / our assets, liabilities, policies, litigations, financial transactions and accounts.

Authorization to Disclose Financial Information to a Government Agency

I / We authorize any financial institution, as defined in the California Right to Financial Privacy Act, to disclose to the City of Sacramento, Revenue Division and its duly authorized representatives, any or all information contained in my / our financial records. Said disclosable information shall include, but is not limited to, all accounts, assets, liabilities, and financial transactions maintained by said financial institution. I / We understand that I / We have the right to revoke this authorization at any time; and further, that in the absence of such a revocation, this authorization will automatically expire one (1) year from the date hereof.

Authorization for Methods of Contact

You agree, that at any time should we need to contact you to collect money owed, we or our collection agency may use various dialing methods in order to reach you. Methods of contact at any number associated with your account including wireless telephone, which could result in charges to you, may include using pre‐recorded/artificial voice messages and/or use of an automatic dialing device as applicable. Our office an/or collection agency may also contact you by sending a text message or emails, using any e‐mail address you have provided. I/We have read this disclosure and agree that the Lender/Creditor/Collection Agency may contact me/us as described above.
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