Payment Arrangement Request Form

107 N. Kimberly Ave, Shawnee, OK 74802-0425
Phone (405) 273-1050
Fax (405) 275-0678
https://ashousingauthority.com
PAYMENT ARRANGEMENT REQUEST FORM
The form is submitted for the purpose of requesting an acceptable payment arrangement to remain compliant with my payment obligations for the Absentee Shawnee Housing Authority (ASHA). You must submit the request at least ten (10) days prior to the due date of your payment.
Today's Date:

MonthDayYear
Date
Program (check one):
Head of Household

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Format: (000) 000-0000.
I request my payment arrangement below be made for the following month:
Check one:
If you checked Partial Payment, describe arrangement:
If you checked Additional Days, please list the days below:
The following are reasons for my failure to make the payment amount due (briefly describe):
WARNING: YOUR REQUEST WILL BE REJECTED FOR REASONS THAT ARE NOT UNUSUAL OR UNEXPECTED EXPENSES, SUCH AS; CHANGES TO NORMAL LIVING EXPENSES, GROCERY BILLS, UTILITY COSTS, STORE BILLS, ETC. WILL NOT BE ACCEPTED.
By signing below, I understand and agree the arrangement made is binding and no alterations to the agreement will be accepted once approved. Should you violate the terms of the agreement, further action will be taken to proceed with the notice of termination of the lease agreement with Absentee Shawnee Housing Authority. Late penalties will be applied even with an acceptable payment arrangement if a past due balance is reflected on your account.
Participant Signature:
Date:

MonthDayYear
Date
Should be Empty:

PAYMENT ARRANGEMENT REQUEST FORM