If you are represented by an attorney, you cannot submit this form. Instead, have your attorney submit this form on your behalf.
The cost to request a payment plan is $150. The fee will be added to your ledger immediately, regardless of whether a payment plan is approved or not.
Submitting this form request a payment plan, but IT IS ONLY A REQUEST. There is no guarantee that your request will be approved.
You will receive notification at the email address provided as to whether your requested payment plan is approved or denied. If your requested payment plan is approved you will receive a Payment Plan Agreement to be signed and returned to our office. If you make a payment prior to receiving notification from our office that your request has been approved, your payment will be processed as a partial payment on the file.
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It is recommended to complete this form from a computer rather than a mobile device.