Payment Arrangement Requests | The Health Coach Group

Name*

First Last

Phone

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Social Security Number (xxx-xx-xxxx format)*

Requests are automatically denied without a valid SSN.

What product, services, or programs are you requesting a payment arrangement for?*

Outline EXACTLY what your proposed payment arrangement is with dates and amounts.*

Please explain your reason for seeking a payment arrangement.*

Consent*

I understand that if I default on payments and fail to cure default within a reasonable amount of time, The Health Coach Group will have the option to declare the entire remaining amount of Principal and any accrued Interest at the current allowable rate immediately due and payable. I will be responsible for all attorney, fees, legal, and collection fees. This is a legal and binding agreement. I agree that this agreement shall be governed by the State of Nebraska in the United States.

Signature*

By typing your name above, you agree to paying your payment arrangement, if approved, on the dates and in the amounts specified and understand and agree to the checkbox above.

Payment Arrangement Form