2. LAKE FOREST PARK MUNICIPAL COURT
4. Promissory Note - Public Defense Services
6. IN CONSIDERATION of legal services rendered and/or to be rendered in Lake Forest Park Municipal Court for the defense of criminal charges against:
8. Case No.
9. Phone No.:
10. Email:
12. First Name*
13. Last Name*
15. Address1
17. Address2
19. City
20. State
21. Zip
23. In consideration of the fact that the undersigned is only partially eligible for defense at public expense, the undersigned promises to pay the sum indicated below to the Lake Forest Park Municipal Court. The undersigned above-named Defendant further certifies that he/she does not have sufficient resources to pay the entire costs of private legal services without substantial hardship to him/herself and/or family.
25. Amount agreed to pay:
26. I request a payment plan for the amount I have agreed to pay

    1. Yes
    2. No
28. Payments can be made in the following ways:
30. 1) Pay online with Visa/MasterCard at www.lfptix.com (6 % fee applies)
32. 2) Pay by phone by calling nCourt at 1-800-701-8560 (6 % fee applies)
34. 3) In person by cash (exact change required), credit/debit (3% fee applies), check or money order.
36. 4) Mail check or money order to Lake Forest Park Municipal Court - 17425 Ballinger Way NE, Lake Forest Park, WA 98155.
38. ** Be sure to include your case number with all payments **
40. After completing and reading the above, please READ and ELECTRONICALLY SIGN, below.
42. If my payment is not received by due date, I understand that my account may be referred to a collection agency and I will be liable for any and all costs.
44. Electronic Signature of Defendant*

    1. I agree. Electronic signature.

    By checking the "I agree" boxabove, you agree andacknowledge that 1) yourapplication will not be signedin the sense of a traditionalpaper document, 2) bysigning in this alternatemanner, you authorize yourelectronic signature to bevalid and binding upon you tothe same force and effect asa handwritten signature, and3) you may still be required toprovide a traditional signatureat a later date.
45. Electronic Signature of Defendant*
    Last name, first name, middle initial
47. Date signed:*
    Date signed:
49. City where electronically signed:*
50. State where electronically signed:*
52. This note becomes VOID and its obligations satisfied to the extent this Defendant pays these attorney fees through the Court OR in the event the fees are waived.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field