Request a Payment Plan

If you cannot pay on time, use this form to submit a request for a payment plan. You will be contacted when your plan is approved or if changes are needed for approval.

Do you want to reduce your LATE FEES? See step 5!

Step 1: Your info

First and Last Name:
E-mail address:
House you live in:
Why your payment will be late:

Step 2: When can you pay?

I will pay in full this month
I will need more than one month to pay in full
I cannot commit to payments at this time, and I am requesting time to find work in order to pay.
Comments on needing more time to pay:

Step 3: Proposed payment plan

Payment 1:

Date: Amount:

Payment 2:

Date: Amount:

Payment 3:

Date: Amount:

Payment 4:

Date: Amount:

Step 4: Source of income

Please provide your sources of income that you are relying on to fulfill this payment plan.

Employer:

Where do you work?
How much do you get paid?
How many hours do you work?
When do you get paid?
Contact number for your employer:

Financial Aid:

What financial aid do you receive?
When do you receive it?
How much will it be?

Family Assistance:

How much?
Who is it from?
Contact Number:

Other (e.g. Tax refund):

What type of income?
How much?

Step 5: Submission

This is being submitted on or before the 5th of the month
This is being submitted after the 5th of the month, and therefore I have included all late fees in this plan.

I understand that this payment plan must meet the requirements in the Payment Plan Policy in order to be accepted.

MEMBER CENTER