Request for payment modification



Please complete all sections of this form and return the completed form via email to MyAccountsCustomerCare@ Or by fax to 888-241-4382We are waiving the $250 per contract fee for this service. Person Completing Form FORMTEXT ?????Date FORMTEXT ?????Time FORMTEXT ?????Customer Full Legal Name FORMTEXT ?????Contact Name/Person Spoke to FORMTEXT ?????Email FORMTEXT ?????Company Headquarters Office Address (Street Name, City, State, ZIP – No PO Boxes) FORMTEXT ?????Phone No. FORMTEXT ?????Billing Address FORMTEXT ?????Fax No. FORMTEXT ?????List all account numbers to be modified: FORMTEXT ?????How many months of payments are you asking us to change or defer with this modification request? FORMCHECKBOX 1 month / 30 days FORMCHECKBOX 2 months / 60 days FORMCHECKBOX 3 months / 90 daysWhen would you like the modified payments to begin? _ FORMTEXT ?????_/__ FORMTEXT ?????__ Month YearWe are experiencing significant volume during this unprecedented time and appreciate your understanding as we work to serve all our customers. While we can’t specify the exact timing, it may be up to 3 weeks before you receive the contract modification from our team after you submit this request. If you have any questions or need further assistance, please contact us using the phone number on your invoice or email us and a team member will be happy to assist you. Sincerely, Customer Care Team ................
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