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  • Payment Plan Agreement
    975 Cobb Place Blvd. Ste – 317 Kennesaw, GA
    30144 Ph: 800-862-7908 Fax: 800-317-0675
  • (Required – No P.O. Boxes Allowed)
  • *Emergency
  • *Emergency
  • *Emergency
  • Payment Plan Fee Requirements:

    I acknowledge that a $35 Application Fee will be charged
    directly to my primary debit card by iCare.

  • Card
    Holder
    Initials
    (Required)
    • 100% of down payment must come from your primary debit card attached to your checking account.
    • Administration Fee of 15% is Non-refundable in the event of a return.
    • Administration Fee is amortized over the duration of your payment plan.
  • PAYMENT PLAN SCHEDULE

    NUMBER OF PAYMENTS MONTHLY AMOUNT MONTHLY PLAN BEGINS
    24 $0.00
  • REVISION / DEDUCTION ONLY
    NUMBER OF PAYMENTS MONTHLY AMOUNT MONTHLY PLAN BEGINS
  • Default and Late Payments: Should you default on any payment obligations as called for in this agreement, iCare Financial and/or Merchant will have the right to declare the entire remaining balance due and payable and all cost of collection, including but not limited to collection agency fees, court costs, and attorney fees. A default occurs when any payment due under this agreement is more than three (3) days late, iCare Financial/Merchant has the right to declare past due balance owed and current or remaining balance due and payable. Should any monthly payment become more than three (3) days past due, you will be charged a $50.00 administrative services fee for each late payment. I authorize and give permission for iCare Financial/ Merchant to contact me via telephone/cell phone/email/mailing address/text message should I default on my payment obligations as called for in the agreement.

  • AUTHORIZATION AND AGREEMENT: We/I hereby request the privilege of paying to iCare Financial under the iCare Payment Plan and hereby request iCare Financial or Merchant to draw items, (checks, ACH, debit, credit card), for the purpose of paying said payments, including any late fees or service fees. I waive the right to dispute charges once services/product is rendered. I authorize iCare Financial to debit the fees/payments listed above from the primary account listed below. I understand and agree that in the event of insufficient funds in the primary account, iCare Financial or Merchant will debit fees from secondary account listed below and or any financial banking account or bankcard I should have in the future. You authorize iCare Financial to charge your primary debit card a $35 application fee for payment plan.

  • (DEBIT CARD MUST BE ATTACHED TO A CHECKING ACCOUNT - NO PRE-LOADED OR PREPAID CARDS ALLOWED)
  • (Please Provide 2nd Credit/Debit Card or must indicate “NOT AVAILABLE”)
  • Subject to the following conditions: 1. The items shall be drawn on the date or dates of this Promissory Note. The transactions on your bank statement will constitute receipts for payment. 2. The privilege of making payments under this Plan may be revoked by the Merchant if any item is not paid upon presentation. 3. This Plan, if cancelled, does not release you from your obligation (Promissory Notes/Contract/Consumer Payment Plan Agreement). 4. Consumers wishing to revoke the ACH authorization must contact iCare within 5 business days before payment date. This in no way nullifies this payment plan agreement/promissory note. 5. A service fee will be assessed for any debit card, draft, credit card, or order returned for insufficient funds or any other reason.

  • 7. I understand and give my consent for Merchant to forward my information to iCare Financial.

  • Fax all iCare Plans to 1-800-317-0675 or Email to admin@dentalassistinginstitute.comicarefinancialcorp.com