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Past Due Balance Payment Arrangement
Parent Name
*
First
Last
Child Name
*
First
Last
Email
*
Phone
*
Responsible Party Name
*
Last Date Of Service
*
MM slash DD slash YYYY
Balance Due On Account
*
Payment Amount
*
Payment Per:
Week
Month
I hereby agree to this payment agreement schedule for charges incurred at Toddler Town Daycare until my account balance is paid in full. My failure to make payments to Toddler Town Daycare will result in further collection action through an outside collection company as stated in the Signed Tuition Agreement. I will also be responsible for all additional fees associated in collection for the past due balance per the agreement.
Date
*
MM slash DD slash YYYY
Phone
*