2. Make sure you have reviewed the eligibility details before submitting this form.
4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address*
10. Citation Number*
11. Vehicle License Plate*
13. Demographic Information*

    We collect this information as part of our commitment to ensure we are creating programs that serve our diverse community. This information is optional. Please Check One:

    1. Black/African-American
    2. White/Caucasian
    3. Hispanic/Latino
    4. Other

    1. Native American
    2. Asian/Pacific Islander
    3. Asian Indian
    4. Prefer Not to Respond
14. Gender

    Please Check One:

    1. Male
    2. Female
    3. Non-binary
    4. Other
    5. Prefer not to Respond

16. Participation in the Citation Payment Plan will be based on a W2 (form) and within the past six months must have met the one of the following income requirements: 

    1. Received government benefits such as food stamps, WIC, Medicare, SSI, unemployment insurance, or COVID emergency relief for financial hardship. 
    2. Children are eligible for free or reduced lunch. 
    3. Live in DHA properties, are eligible for Section 8 housing, or qualify for property tax assistance.
    4. Experiencing homelessness.
    5. Income at or below 200% of the current federal poverty level (see chart below).

     

    Household Size	1	2	3	4	5
    Annual Income	$25,520	$34,480	$43,440	$52,400	$61,360
    Monthly Income	$2,127	$2,873	$3,620	$4,367	$5,113

    
    

    Once this form is submitted, a member of our staff will contact you to certify proof of eligibility (e.g., driver’s license, proof of income, citations fees equal to or more than 100 dollars, proof of receipt of public assistance benefits). Documents will not be copied, scanned, or kept. The documents will merely be reviewed in person.

    Once an applicant has been approved for the program they will be required to create an account in AIMS, our customer portal, and sign a contract agreeing to the terms and conditions of the Citation Payment plan at the Park Durham Customer Service Center.

    The application and a payment plan contract will be scanned and uploaded/attached to the existing citation account and will receive a monthly statement via email with a minimum payment due by the 15th.  

    Applications are also available in our Park Durham Customer Service Center, located at 105 W. Morgan St., Suite 104. Our staff will be happy to assist you Monday through Thursday from 8 a.m. to 5 p.m., and on Friday from 10 a.m. to 5 p.m.  

    Terms of Payment Plan

    1. An initial payment equaling 10% of the total owed must be paid immediately upon application approval.
    2. A minimum payment equaling 10% of the original total owed must be paid monthly. 
    3. Monthly payments are due the 15th day of each month. 
    4. The Citation Payment Plan must be paid in full within one year of the original plan start date. 
    5. Only one (1) payment plan can be in effect at any given time. 
    6. Failure to make payments on time may result in the cancellation of the payment plan.

     

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

    This field is not part of the form submission.

20. Submit

* indicates a required field