Payment Plan Application

To apply for a payment plan, please complete this form and press the send button. Your answers to these questions help our client better understand your ability to pay. We will respond to you promptly. Thank you.

Required fields are marked with an asterisk (*).

* First Name:
* Last Name:
Do you have a file number?	(Ex. Number: 00-00000)
* Date of Birth:	Please enter date in a mm/dd/yyyy format
* Last four digits of Social Security No:
* Street Address:
Apt. No.
*City:
*State:
*Zip Code:
*Home Telephone No.:
Cell phone No.:
*Email address:
*Are you employed:	-Yes -No
Full time or part time:	-Full -Part -N/A This is a required field when you are employed. Please select an option other than N/A when employed.

Employer Information

* Employer Information is required when you indicate that you are employed.
*Name of Employer(s):
*Street Address :
Suite No:
*City:
*State:
*Zip Code:
*Phone:
*Date of Hire:	Please enter date in a mm/dd/yyyy format
*Can you receive calls at work?	-Yes -No
*How often are you paid?	-Weekly -Bi weekly -Monthly -N/A Please select an option other than N/A when employed.
* Hours worked per pay:
*Average take home pay (after taxes):	$
*Please indicate the period being used to report your salary:	-Weekly -Bi weekly -Monthly -Yearly -N/A Please select an option other than N/A when employed.

Are your wages currently being attached or garnished?	-Yes -No
If yes, is the wage attachment for child support?
How old is the child(ren)?
If you are not employed, please indicate if you receive child support, unemployment compensation, disability income insurance, alimony, SSI or other compensation?
Do you receive any other forms of financial assistance? (Examples: food stamps, Section 8 housing, Medicare, help from family)
Are you able to work?	-Yes -No
Are you in the military?	-Yes -No
Is your spouse in the military?	-Yes -No
Are you a veteran?	-Yes -No
Disabled veteran?	-Yes -No
Rent payment per month	$
Are you paying your rent on time?	-Yes -No -N/A
Mortgage payment per month	$
Are you paying your mortgage on time?	-Yes -No -N/A
Car payment per month	$
Are you paying your car payment on time?	-Yes -No -N/A
* Do you prefer to make payment: - on the 1st of the month - on the 15th of the month How much can you pay a month?
If you need more room to complete an answer, or would like to add additional information about your financial situation, please enter below.
I certify that the foregoing statements are true. I give permission to Clark C. Kingery, P.A. to verify these statements. The electronic signature appearing below is mine.
* Signature: (type full name) * and Dated:

   

This communication is an attempt to collect a debt and any information obtained will be used for that purpose. This information is not intended to be legal advice. If you have questions, please consult an attorney.