Waiver Payment Plan Request Form

2. **Disclaimer**
   This is a request for the Waiver Payment Plan Program **You must have a valid email address to participate in the program** Once submitted, the court will email you the completed document for your review and signature.
4. Bratenahl Mayor's Court Waiver Payment Plan * Please see Waiver Schedule Page for violation amount *
   Please fill out the required infomation below. This is a 60-day payment plan. The initial $75.00 is due within 3 days of receipt of the signed document. If the payment is not made within that time, the plan goes into default and the original waiver amount will be due on or by your scheduled court date. Payments can be made over the phone Monday - Friday and in person Tuesday, Wednesday, and Thursday, 9am-4pm.
6. Date*
   Date
8. Ticket Number*
10. First Name*
11. Last Name*
13. Phone Number*
15. Email Address*
Leave This Blank:


17. 1. Receive an email copy of this form.
18. Email address

    This field is not part of the form submission.

19. Submit Submit and Print

* indicates a required field