Payment Plan Agreement

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Payment Plan Agreement
Creditor:
Date:
Address:
Debtor:
Address:
City/State/Zip:
E-mail:
I, the undersigned member, agree to make payments on the specified dates and the agreed amounts
state on the payment schedule below to the creditor. I understand the consequences that will be brought
against me if the contact if violated. The penalties could include: account being turned over to collection
agency and/or prosecution in a small claims court. Upon default, I agree to pay any fees and costs that
the creditor may incur in collecting my balance owed as well as a competitive interest rate on the amount
owed.
Total amount owed (beginning balance) .......................................................................... $
Payment Date
Payment Amount
Balance
I agree that the above schedule of payments is an acceptable resolution to help retire my debt with the
creditor, and I remain current with this payment plan.
Debtor
Date
Creditor
Date
Revised 08/06

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