Request For Payment Form printable pdf download

Request For Payment Form

Request for Payment

Date: ______________________________ , 20 _____

To:____________________________________________________

RE: Payment of Your Account

Dear ________________________________ :

Regarding your account, please be advised that we show the following outstanding balance on

our books:

Invoice # __________________

Date ________________

Amount

$ __________

Invoice # __________________

Date ________________

Amount

$ __________

Interest on account at __________ percent

Amount

$ __________

Late charges

Amount

$ __________

Less credits and payments

Amount

$ __________

TOTAL BALANCE DUE

AMOUNT

$ __________

Please be advised that we have not yet received payment on this outstanding balance. We are

certain that this is merely an oversight and would ask that you please send the payment now.

Please disregard this notice if full payment has been forwarded to us.

Thank you for your immediate attention to this matter.

Very truly,

_____________________________

Signature

_____________________________

Printed Name

Request For Payment Form