請求准予分期繳納罰金聲請表 Application to Pay the Fine in Installments 案號： 年度 字第 號 股別： Case No.: year zhi No. Section:
聲 請 人 Applicant Name	性別 Gender	出生年月日 Date of Birth	國民身分證統一編號/護照號碼/居留證號 National ID No./ Passport No./ Alien Resident Certificate No.	職業 Occupation
Address	Tel.	備考 Remarks
The Request
一、受刑人 （國民身分證統一編號 ） 因 案件， □銀元 元，折合新臺幣 元 應繳納罰金 ， □新臺幣 元 並經 貴署通知 年 月 日到案執行。 1. The sentenced person (National ID No. ) of the case of has been sentenced to □ silver yuan, converted into NT$ pay a fine of □NT$ and has been notified to appear at your Office on [month] [date], [year] for execution. 二、因受刑人經濟困難，無力一次繳清，請准予分 期繳納。 2. The sentenced person is unable to pay the fine in one lump sum due to economic hardships. Please grant the permission to pay the fine in installments. 三、聲請人為受刑人：□配 偶 □法定代理人 □家 屬 3. The Applicant is the □Spouse □Legal representative □Family member of the sentenced person.
此 致 臺灣嘉義地方檢察署公鑒 TO Taiwan Chiayi District Prosecutors Office 聲請人 (簽名蓋章) Applicant (Signature/Stamp) 中 華 民 國 年 月 日 Date: (mm)/ (dd), (yyyy)

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Note: This free legal form can only be used for application in the Prosecutors Office with jurisdiction.