Past Due Balance Payment Arrangement

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Parent Name*

First Last

Child Name*

First Last

Email*

Phone*

Responsible Party Name*

Last Date Of Service*

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*

Phone*

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