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Payment Agreement Level 1-3 months

Participant's Full Name:

Late Payments

Timely payments are important to the success of your DUI Program. Invoices are posted and payments are due on the 1st day of each month. If a payment is late, the following will occur:

Days Late

5 days - A reminder is sent to the client.
11 days - $25 late fee is applied to the client's account.
15^th day of the month - Suspended from services until payment is paid. F2F will still be scheduled and you are expected to attend
30 days - The client is on a 30hold and will not receive any services until payment is received.
60 days - The client is terminated from the DUI Program.

Please note: Suspension/30Day hold releases take 48 hours to process.

Payment Options: Payments can be made by money order, cashier’s check, or credit/debit card. Participants will receive a receipt for each payment received for credit/debit card payments made onsite at Second Chance DUI Program.

Financial Assessment: If a participant feels they are unable to make the monthly payment they must request a financial assessment to determine if they qualify for an extended payment plan or if their income is at the General Assistance level. I understand that a financial reassessment will be conducted if my scheduled payment is delinquent 30-days or more; or prior to dismissal from the program for failure to pay the program fee.

Failure to Pay: If a participant fails to make payments in full and on time without requesting or attending a financial assessment this is considered failure to pay; and will result in dismissal from the program.

Payment Structure

	Level 1 3-months
Down Payment	$ 135.00
Monthly/Length	$144 x 3-months
Total	$ 567.00

Payment Schedule for Level 1 - 3 months

Total Program Fee	$567.00
Down Payment Paid	$135.00
Balance Due	$432.00
Monthly Payment Amount	$3 payments of $144

Monthly Payments Begin On: The first day of the month following enrollment.

Additional Fees: Charged and due when incurred

Missed Activity: Absence or Reschedule	$25
Reinstatement After Dismissal	$67
Transfer In/Out	$55
Leave of Absence	$55
Non-Sufficient Funds	$39
Late Payment Fee	$25
Duplicate DMV Certificate	$25

Agreement

I have read this document and agree to attend and provide payment as outlined in the above payment schedule for the DUI Program level I am enrolling in today at the Second Chance DUI Program.
The Second Chance Program allows a participant to pay in advance of services to be provided. Refunds shall be provided for any fees paid in advance for services not provided.
I have received a copy of this signed document for my records.
I am liable for the total program fee, as well as, any additional fees, which the program is approved to assess.
I understand that if I fail to pay for program services received the amount of money owed to Second Chance may be sent to a collection agency.
I understand and agree that the Department of Motor Vehicles completion certificate will not be issued until all program fees and any additional fees accrued during my enrollment have been paid in full.

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Timestamp

Audit

January 10, 2021 8:17 pm MDT

Payment Agreement Level 1-3 months Uploaded by Heather Kim - dui@screcovery.org IP 69.136.118.15

January 13, 2021 4:18 pm MDT

Document owner janiceadayforbes@gmail.com has handed over this document to pam@screcovery.org 2021-01-13 16:18:04 - 73.96.29.235

May 16, 2022 12:55 pm MDT

Document owner pam@screcovery.org has handed over this document to Heather@screcovery.org 2022-05-16 12:55:51 - 71.228.156.29