Customer Agreement to Extend Debt Payment by Installment PlanAriel Vickery2020-06-09T10:54:54-05:00

Customer Agreement to Extend Debt Payment by Installment Plan
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Customer Additional Agreement Terms
Check each statement below to acknowledge agreement.
I,
(the Customer) agree to the following statements:*
- The information found on the above portion of this document, including my contact information, is true to the best of my knowledge.
- I presently owe the Company the balance due as outlined in the above portion of this document.
- I agree to pay the said debt on the extended terms also outlined in the above portion of this document.
- I understand the first installment payment of the extended terms is due on the date this document is submitted to the Company.
- I understand that, in the circumstances a payment I have made is rejected the extended terms of this Agreement will be terminated and an additional $25 fee will be added the remaining balance due.
- I understand that in the event I am unable to make any payment punctually on the agreed extended terms, or default on a payment for any other reason, the Company will have full rights to proceed for the collection of the entire balance remaining, including any incurred fees.
- I understant that, in the event this Agreement is terminated due to default, I am responsible for all attorney and court related costs as well as any damages incurred by the Company while attempting to collect the past due amount.
Signature*
By signing you agree that you have read, understand, and accept the terms of this agreement.
Date
MM slash DD slash YYYY
This field is hidden when viewing the form
Phone
Email
Choose Your Payment Method
Choose Your Payment Method*
- I would like to set up recurring payments to be automatically charged to my financial account when my payments are due. (You will an email notification before your payment is processed and receive a receipt after the payment has been processed.
- I would like to make my payment manually at the time they are due. (By choosing this option, you will need to complete your first payment now. For remaining payments you will receive a reminder email notification with a link to pay by credit/debit or bank transfer prior to the payment due date.)
Recurring Payment Options
- Bank Transfer
- Credit/Debit Card
Check each box below to agree to the statements.
- I authorize JV Garage Door, LLC to electronically debit my bank account according to the terms outlined in the above portion of this document. I acknowledge that electronic debits against my account must comply with United States law.
- This payment authorization is to remain in effect based on the terms of this Agreement, or until my balanced owed is $0, or until I notify JV Garage Door, LLC of its cancellation by giving written notice in enough time for the business and receiving financial institution to have a reasonable opportunity to act on it.
Name on the account:
First Last
Routing Number
Account Number
Cardholder Name
Billing Adress
- Same Address listed on top portion of this document
- Add a new address
Street Address Address Line 2 City State ZIP Code
Type of Card
- Visa
- MasterCard
- Discover
- American Express
Card Number

Card Number
Month
Month
Year
Year
CVV
Check each box below to agree to the statements.
- I authorize JV Garage Door, LLC to charge my credit card account according to the terms outlined in this Agreement. I acknowledge that credit card charges against my account must comply with United States law.
- This payment authorization is to remain in effect based on the terms of this Agreement, or until my balanced owed is $0, or until I notify JV Garage Door, LLC of its cancellation by giving written notice in enough time for the business and receiving financial institution to have a reasonable opportunity to act on it.
Total Amount Due Today
Price:
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Signature*
Sign above to authorize payment.
Select the Submit button below to complete Customer Agreement to Extend Debt Payment by Installment Plan. A copy of the agreement will be emailed to you for your records

816-875-8872

Customer Agreement to Extend Debt Payment by Installment Plan

Customer Additional Agreement Terms

Choose Your Payment Method

816-875-8872