Payment Plan Agreement

Chapter:                                                                                            Date:                                                       Host Institution:                                                                                                                                                

Member Name:                                                                                                                                                 Address:                                                                                                                                                            City/State/Zip:                                                                                                                                                   E-mail:                                                                                                                                                               Check one:       ‰ alumnus        ‰ undergraduate

I, the undersigned member, agree to make payments on the specified dates and the agreed amounts state on the payment schedule below to the chapter.  I understand the consequences that will be brought against me if the contact if violated.  The penalties could include:  account being turned over to collection agency, expulsion from the Fraternity, and/or prosecution in a small claims court.  Upon default, I agree to pay any fees and costs that the chapter may incur in collecting my balance owed as well as a competitive interest rate on the amount owed.

Total amount owed (beginning balance) .......................................................................... $                        

Payment Date	Payment Amount	Balance	
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I agree that the above schedule of payments is an acceptable resolution to help retire my debt with the chapter, and I remain current with this payment plan.

Member	Date	Chapter Treasurer	Date

Revised 08/06