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MONTHLY PAYMENT PLAN APPLICATION ID NO. NAME: ADDRESS: PHONE #: E-MAIL: I Agree to pay all charges with a 6 Month Plan For Services Rendered: initial DISCLOSURES: ***DUE DATE: PP/CK/CH *CHARGES: FEE **DATE PAID INT 1 TOTAL CHARGES $ - 2 20% OF DUE BILL $ - 3 1ST PAYMENT $ - 4 2ND PAYMENT $ - 5 3RD PAYMENT $ - 6 4TH PAYMENT $ - 7 5TH PAYMENT $ - 8 6TH PAYMENT $ - PROMISSORY NOTE: For and in consideration of the above application, and subject to all the provisions thereof, I hereby promise to pay ASTRON BUSINESS & TAX SERVICES, LLC, of Accounting and Administration Management the sum of $ $ - and any additional charges add to this agreement as stated and disclosed above. I am aware that this contract is legal and binding upon me. I acknowledge that I have received a copy of this agreement. I have read and agreed to ALL information this payment plan has set forth herein. I understand that if I submitt any credit/debit card information on this form it will be charged on the due date with no hesitation. I understand a $15.00 fee will be added every week for late payment. CLIENT SIGNATURE DATE SPOUSE SIGNATURE DATE TONI WOODS-FULLER, V.P ADMINISTRATION DATE EXTENSIONS (OFFICE USE ONLY) $5.00 ADDITIONAL FEE EXTEND # PAYMENT OF $ TO: ADMINISTRATION INT. TYPES OF PAYMENT WE ACCEPT ~CREDIT/DEBIT CARD ~MONEY ORDERS ~REFERRAL REFUNDS ~CHECKS ($30.00 NSF CHARGE) ~PAY PAL ~POST DATED PAY ****If paying by credit card complete below: CARD TYPE: BILLING ADDRESS: MONTHLY PAYMENT $ CITY, STATE, ZIP: CARD NUMBER: CARDHOLDER NAME: SEND RECEIPT? YES NO Exp. Date: CVA Code SIGNATURE *Change amount according to your amount due. ** Any additional amount you want to pay extra. *** Usually on issue for 1st, 15th, and 30th. However those who would like biweekly add dates. **** Should be filled out completely for all automatic withdrawls.
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