PAYMENT ARRANGEMENT AGREEMENT. Thank you for choosing Family Center for Health Care for your family’s health care needs. We are always willing to work with individuals as they try to manage their financial responsibilities for their clinic accounts. The purpose of this form is to set your account up on a monthly payment plan agreed upon by yourself and the clinic. You are responsible for making a payment each month to keep your account current. If you are unable to make your monthly payment, you must contact the clinic ahead of time and make us aware of your situation. Failure to do so will result in a delinquent account balance. Note: If your account was in pre-collections on the date you signed this form, it is vital you make your monthly payments to avoid being sent to collections. Should your account again become delinquent with two consecutive missed monthly payments, and no communication on your part to remedy the situation, your account will be sent to collections immediately following the second missed payment. Account Guarantor: Patient Names on Account: My current total account balance is $ . My account is in pre-collections: Yes No I agree to make monthly payments of $ , by the (day) of each month (ex: 1st, 10th, 15th, etc.). Please select one: My first payment will be made by (date) , or My first payment of$ is enclosed. By signing this agreement, you are pledging to make your required monthly payments as described above. Thank you for resolution of your account. Name (Print) Phone Number/s Signature Date
PAYMENT ARRANGEMENT AGREEMENT. A contract between the customer and the City allowing the customer to make payments to the City to pay any current charges or portion thereof for any municipal utility by a determined date.
PAYMENT ARRANGEMENT AGREEMENT. The City of Arlington offers a payment schedule to delinquent residential customers of all income levels who are willing to make payment arrangements. The City may enter into a written Payment Arrangement Agreement for a customer’s municipal utility bill on a case-by-case basis. Verbal agreements will not be accepted. If the customer continues to make their payment arrangements on time, the City will not disconnect the customer’s service. Failure to keep payment arrangements, will result in an immediate disconnect. Under this plan, a customer may change its initial payment schedule in writing, if done before the disconnection, with approval of the City of Arlington.
