Payment Plan Affidavit Granting Authority To Act - Nyc Department Of Consumer Affairs
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1PAYMENT PLAN
AFFIDAVIT GRANTING AUTHORITY TO ACT
Date:
Summons and/or Fee Number(s):
.
I,
, attest, under penalty of perjury, to the following:
1) I am the owner/corporate officer/principal of
located at
. A true and accurate copy of my
government issued photo identification is attached to this affidavit.
2) I authorize
, whose
telephone number is
, and e-mail address is
,
to enter into a Payment Plan Agreement for the above Summons and/or Fee Number(s) on my
behalf or on behalf of the above business.
3) I understand that I or my business will be bound by the terms of the payment plan agreement
signed by my authorized representative.
_________________________________
Signature
Sworn before me this ___________________ day of ________________________, 20_______
________________________
NOTARY PUBLIC
Revised 07-12-17 NS
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