Home
Services
About
Contact Us
Menu
Home
Services
About
Contact Us
BTP Fees Payment Assessment/Agreement
01
Initial Contact and Intake
02
Program Contract
03
Waiver of Confidentiality
04
Promise to Maintain Confidentiality
05
Program Policy
06
BTP Fees Payment Assessment
07
Drug and Alcohol Assessment
08
Risk Assessment
BTP Fees Payment Assessment/Agreement
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
Participant Name
Court Case Number
Xref
BTP Program File #
Monthly Income
Gross Wages, Salaries, Bonuses, Commissions, Tips
Net profits from Self-Employment
Net income from Real or Personal Property
Spousal Support
Social Security
Retirement
Unemployment Compensation
Union Funds
Worker's Compensation
Veterans Benefits
Educational Grants
Training Stipends
Public Assistance
GA- General Assistance
SSI/SSA/SDI
Social Security Benefits
Emergency Assistance
Non-Federally Funded General Relief
Cal WORKS (California Work Opportunities & Responsibility for Kids)
Total Gross Monthly Income (All Sources)
Monthly Expenses
Mortgage/Rent
Food
Auto Loan/Fuel/Insurance
Child Care
Spousal/Child Support
School
Others (Specify)
Other Additional Pages
Amount
Utilities Expenses
Electricity
Gas
Water/Garbage
Telephone
Court Ordered Fines/Fees
Medical expenses
Total Monthly Expenses (All Sources)
Date
I understand and agree to abide by all terms of this Fee Payment Agreement, and to inform BTP within no later than seven (7) days of any changes in my monthly income level or source of income. I understand that the program may conduct a financial assessment to re-assess my eligibility for an adjustment of program fees.
Participant Signature
❌
Date
I disagree with the recommended Program Fee amount and request to set a hearing to determine my ability to pay the program fees. See Hearing information below (to be scheduled for the next court appearance already set or new date to be selected by the BTP provider)
Participant Signature
❌
Date
Proof of the amount and source of income, if any, must be brought to court on the following date.
Date
Failure to appear or failure to bring the required proof of income may result in the court finding you are able to pay the assessed program.
Submit
Home
Services
About
Contact Us
Home
Services
About
Contact Us