Scheduled Payments Plan Request Form

Scheduled Payment Plan

Request Form
NOTICE: Information submitted via this form is strictly confidential and will only be reviewed by the EMPOA board, EMPOA Financing Committee, TN Comptroller auditors and/or IRS auditors. Submitted information must be securely retained only for governmental auditing purposes and will not be shared with any additional private organizations and/or entities otherwise. Scheduled payment plans are approved on a case by case basis. All decisions regarding approval are made at the discretion of the EMPOA board and Finance Committee.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please list one of your EMPOA lots so we can find your account
Section# and Lot# (leave blank if unknown)
Please select which best applies
On what date do you plan to have all past-due balances fully paid?

MonthDayYear
Date
What is the maximum monthly payment amount in which you realistically believe you can afford.
Please let us know of any other pertinent information which should be considered in this matter.
By signing below, you confirm that the information submitted is accurate to the best of your knowledge. To edit or redact any submitted information, please contact the Finance Committee at finance@englishmountainpoa.com
Should be Empty:

Scheduled Payment Plan