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Payment Plan Request

HOAM Demonstration Site

123 Anystreet • Anytown, Texas 12345 • (214) 555-1212

https://www.surehoa.com/

Payment Plan Request

Homeowners that are unable to pay their annual assessment or other fees in full due to financial hardship may request a payment plan.

Please note, interest shall accrue on the unpaid balance at the rate of 18.00% percent per annum, compounded monthly. Accrued interest shall be added to the unpaid balance.

Your first payment must be submitted along with this plan in order for it to be valid.

Print Full Name

Address

Telephone Number

Email Address

Today's Date

Briefly describe your reason for this request:

Payment Plan (Payment amount and term requested, eg. "$50 the first of each month."):

Payments must be no less than $25.00 per month. If a payment is late, a penalty of $15.00 shall be added to the unpaid balance. If a check tendered is returned or declined a charge of $35.00 shall be added to the unpaid balance of the loan, and all future payments shall be accepted only in guaranteed funds (money order or certified check). Failure to follow the payment plan will result in immediate collection action.

Payment Amount and Frequency

Payment plans may not be for terms longer than 18 months.

Final Payment Date

Signature