Consumer Expense Agreement

Consumer Expense Agreement
Consumer Name:

First NameLast Name
Consumer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number:
Date Of Birth:
Consumer Telephone Number:
Please enter a valid phone number.
The above named individual agrees to pay Connext Care, LLC for

Room & Board (Rent, Utilities, and Food Costs)RoomUtilitiesCableWaterTrash RemovalLawn ServicesFood CostsToiletriesTelephone
By the Day of every month.
Monthly Amount of:
Consumer Signature:

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Date Consumer Signed:

MonthDayYear
Date
Connext Care, LLC Representative Name:
Connext Care, LLC Representative Signature:

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Date Representative Signed:

MonthDayYear
Date
Remit Payment to:

Connext Care, LLC

7449 W. Gulf to Lake Hwy.

Suite 3

Crystal River, FL 34429
Should be Empty: