Payment Agreement Level 1-3 months
Participant's Full Name:
Late Payment: The monthly payment is due on the 1st or the 15th of each month as specified in the Payment Contract.
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.
$144 x 3-months
Payment Schedule for Level 1 - 3 months
Total Program Fee
Down Payment Paid
Monthly Payment Amount
$3 payments of $144
Monthly Payments Begin On: Select Today's Date. for one months.
Additional Fees: Charged and due when incurred
Absence or Reschedule
Reinstatement after Dismissal - $ 67
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Payment Agreement Level 1-3 months
Agree & Sign