PO BOX 59440
Chicago, IL 60659
Phone: 866.993.0995
Fax: 773.293.4042

Payment Application



Please fill out the following form:
First name:
Last name:
Do you have a file number?
(example: E02-2222)
Date of Birth:
Street Address:
City:
State:
Zip Code:
Home Telephone no.:
Cell Phone no.:
Email Address:
Are you Employed?
Yes No
Full time or part time:
Full Time Part Time Not Applicable
Last four digits of your social security number:
 
 
Employer Information
* Employer Information is required when you indicate that you are employed.
Name of Employer:
Street Address:
City:
State:
Zip Code:
Phone:
Date of Hire:
Can you recive calls at work?
Yes No
How often are you paid?
Weekly bi-weekly Monthly Yearly Not Applicable
Hours worked per pay:
Average take home pay (after taxes):
 
Please indicate the period being used to report your salary:
  Weekly bi-weekly Monthly Yearly Not Applicable
 
 
Are your wages currently being attached or garnished?
  Yes No
If yes, is the wage attached for child support?
 
How old is the child (ren)?
If you are not employed, please indicate if you receive child support, unemployment compensation, disability income insurance, alimony, SSI, or other compensation?
 
Do you receive any other forms of financial assistance? (Examples: food stamps, Section 8 housing, Medicare, help from family)
 
Are you able to work?
Yes No
Are you in the military?
Yes No
Is your spouse in the military?
Yes No
Are you a veteran?
Yes No
Disabled veteran?
Yes No
Rent payment per month?
Are you paying your rent on time?
Yes No Not Applicable
Mortgage payment per month?
Are you paying your mortgage on time?
Yes No Not Applicable
Car payment per month?
Are you paying your car payment on time?
Yes No Not Applicable
     
Do you prefer to make payments:
Weekly Bi-Weekly Monthly
For the monthly payment option, please choose a day between the 1st and the 28th day or the month that is most convenient for you to make your payment.
 
How much do you propose to pay?
If you need more room to complete an answer, or would like to add additional information about your financial situation, please enter below.
 
 
 
*I certify that the following statements are true.  I give permission to The Law Offices of Brian S. Glass, P.C. to verify these statements. The electronic signature appearing below is mine.
Signature:  
Date: