Monthly Payment Plan Form (Page 2 of 2) in pdf

Prepayment

Additional payments over the basic schedule may be made at any time without penalty for prepayment.

Payment

Participants (students) will be e-billed for the amount due on a monthly basis. Hard copy bills will be produced twice a year:

mid-summer for fall classes and mid-December for spring classes.

Please accept this as my application for participation in the Stetson MPP program.

To avoid processing delays, please complete all questions. (Please print, unless otherwise noted.)

THIS SECTION IS MANDATORY & MUST BE COMPLETED BY THE STUDENT

MPP IS NOT VALID WITHOUT 20% COMMITMENT PAYMENT

YOU MUST COMPLETE A NEW APPLICATION EACH ACADEMIC YEAR

Student Name____________________________________________________________ ID___________________________

Address______________________________________________ City, State, Zip____________________________________

Additional e-bill address (Parent): __________________________________________________________________________

I agree to the terms and conditions of this plan____________________________________________ Date________________

(Student signature MANDATORY)

THIS SECTION IS OPTIONAL.

DO NOT COMPLETE IF YOU DO NOT WANT YOUR PAYMENTS AUTO-DRAFTED.

Stetson University Authorization Agreement for Pre-authorized Payments (ACH Debits)

I hereby authorize Stetson University to initiate debit entries to my checking account (financial institution indicated below) on

the 15th of every month in accordance with my Monthly Payment Plan (MPP). This authorization is to remain in full force

and effect through the current academic year until Stetson University has received written notification from me a

minimum of 10 days prior to the next scheduled debit of its termination.

**CHECKING ACCOUNTS ONLY**

BANK ROUTING NUMBER____________________________________________________________________

BANK ACCOUNT NUMBER___________________________________________________________________

**PLEASE ATTACH A VOIDED CHECK TO ASSURE ACCURACY**

ACCOUNTHOLDER’S NAME___________________________________________________________________

ACCOUNTHOLDER’S ADDRESS________________________________________________________________

____________________________________________________________ ZIP______________________________

DAYTIME PHONE __________________________EMAIL ___________________________________________

SIGNATURE__________________________________________________________DATE__________________

Application Deadline

Applications are not accepted after July 30

You may return this completed form by posting, emailing, or faxing to: Bursar’s Office, 421 N. Woodland Blvd, Unit 8348,

DeLand FL 32723 stuaccts@stetson.edu fax: 386-822-7126 phone 386-822-7050

*********************************************************************************************

For Office use only: MPP dollar amount.____________________ Monthly payment________________________

Input by:____________________ Date: ________________

Monthly Payment Plan Form Page 2