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Account Number*

Last Name*

First Name*

Middle Initial

Street

City/State

Zip Code

Daytime Phone*

Evening Phone*

Best time to call*

If you would like to set up payment plan terms you must comply with the following guidelines.

1. Payments must be received every 30 days.
   

2. Payment plans must not exceed 12 months.
   

3. First payment must be received within 30 days of today's date.
   

4. Payments should be of equal or relatively equal amounts.
   

5. All payment plans must be approved and acknowledged. Please make certain you complete the can be reached fields on this form.
   

6. You must specify the method in which payment will be transmitted.
   

Thank you

I would like to set up the following payment plan terms. Payment will be delivered by check, credit card, money order etc. Please enter your choice here .

I understand the this plan must be confirmed before it is deemed valid. I can be reached during the day @ or in the evening @

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Due Date

Payment no. 1

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Payment no. 2

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Payment no. 3

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Payment no. 4

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Payment no. 5

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Payment no. 12

$

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