PAYMENT AGREEMENT
I understand and agree that I am financially responsible for payment of all services received in the amount stated below. I agree to pay the amount in the time period stated below.
I understand that any remaining balance not paid in full will accrue a monthly service charge at [SPECIFY] % (minimum monthly service charge of [SPECIFY] $).
For professional services rendered or [SPECIFY], I agree to pay [YOUR COMPANY NAME] the total sum of [SPECIFY] $.
Customer name: _______________________________________________________
Customer address: ______________________________________________________
Account No: ____________________________________________
Payment amount: $_________________ Weekly / Bi-weekly / Monthly
First payment date _________________
Last payment date _________________
Payments shall be deemed delinquent if not received at the payment date. If any scheduled payment related to this agreement is deemed delinquent during the term of this agreement, the agreement shall be considered to be in default, and the entire amount, penalty, and interest owed shall be due and payable immediately.
___________________________________________ _________________
Client signature Date
____________________________________________ _________________
Staff Witness signature Date
