Payment Agreement Level 3-9 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. 

Payment Structure


Level 3


Down Payment

$ 147.00



$105.00 x



$ 1,092.00


Payment Schedule for Level 1 - 3 months

Total Program Fee


Down Payment Paid


Balance Due


Monthly Payment Amount

$105.00 for 9 months

Monthly Payments Begin On: Select Today's Date. for one months.

Additional Fees: Charged and due when incurred

Absence or Reschedule

  • Group or Education - $ 25
  • Face to Face - 18-Month Program - $25
  • Face to Face - Wet Reckless, 3, 6, 9-Month - $25

Reinstatement after Dismissal - $ 67


  1. 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.
  2. 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.
  3. I have received a copy of this signed document for my records.
  4. I am liable for the total program fee, as well as, any additional fees, which the program is approved to assess.
  5. 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.
  6. 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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Document name: Payment Agreement Level 3-9 months
lock iconUnique Document ID: 72d9fb021a8517ec6264e4595785016fcce74d83
January 10, 2021 8:39 pm MDTPayment Agreement Level 3-9 months Uploaded by Heather Kim - IP
January 13, 2021 4:17 pm MDT Document owner has handed over this document to 2021-01-13 16:17:10 -
May 16, 2022 12:55 pm MDT Document owner has handed over this document to 2022-05-16 12:55:19 -