Payment Agreement Template

This Payment Agreement confirms the terms and conditions regarding the payment of an outstanding balance owed by the Debtor. Please complete the details below and return this form to acknowledge and accept the payment plan.

Account Information

Debtor Name:

Amount Owed:

Payment Plan

Total Number of Payments:

Amount per Payment:

First Payment Due Date:

Subsequent Payment Due Dates:

Terms & Conditions

By signing below, the Debtor agrees to make scheduled payments according to the plan outlined above. Failure to comply with the agreed-upon terms may result in further collection actions, which may include legal action or referral to a debt collection agency.

Agreement Acceptance

Debtor Signature:

Date:

Creditor/Company Representative Signature:

Date: