City of Lake Mills, Wisconsin

On the shores of Rock Lake

Payment Plan Application

THE JUDGE WILL REVIEW THIS APPLICATION AND YOU WILL BE NOTIFIED BY MAIL OF HIS DECISION. IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE LAKE MILLS COURT CLERK AT 920-350-7063.

I UNDERSTAND IT IS MY RESPONSIBILITY TO KEEP THIS COURT UPDATED ON ANY ADDRESS CHANGE. I FURTHER UNDERSTAND THAT NONCOMPLIANCE WITH THIS PAYMENT PLAN WILL RESULT IN ONE OR MORE OF THE FOLLOWING: SUMMONS TO REAPPEAR IN COURT, 1 YEAR SUSPENSION OF MY DRIVER’S LICENSE, TAX INTERCEPT, STATE DEBT COLLECTION, OR A WARRANT FOR MY ARREST.

Notice of Intent to Certify Debt Pursuant to Wisconsin State Statutes 71.935, you are hereby notified that the amount noted above will be filed with the Wisconsin Department of Revenue. This debt will remain certified with the Wisconsin Department of Revenue until it is paid in full. You have the right to appeal this action. An appeal must state the specific grounds for objection and must be postmarked within ten business days from this notice. Appeals must be mailed or delivered to Lake Mills Joint Municipal Court, 200D Water Street, Lake Mills, WI 53551.

*Full Name:


*Date of Birth:


*Street Address:


*City, State, ZIP:


*Telephone Number:


*Social Security Number:


*Driver's License/State ID Number:


*Place of Employment:


*Employer Phone Number:


*Please list relevant citation numbers:


*Please list amounts owed for each citation (in same order if applicable):


*Total Amount Owed:


*Please describe your proposed payment plan per month:


*I have read and consent to the notices listed at the top of this form:
I consent

*Please enter your full name to serve as an electronic signature:

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