Payment Plan Request Form

Name of Parent/Guardian/Caregiver

requesting payment plan:

________________________________________________________

Student Name: ___________________________________________ Grade: ____________________

Details of Payment Plan

Payment Increments:

Weekly

Fortnightly

Monthly

Other (please state) __________________________________

Amount of Payment per Increment: $______________

Method of Payment Plan:

Direct Debit

CentrePay

Other (please state) _________________________________________________________________

For all payment plan requests by parents/guardians/caregivers, an appointment with Sue Higgins (Principal) is

required. The office will contact you to confirm a time.

Signature: ______________________________________________ Date: ________________________

Administration Use Only

Statement Attached:

Prepared by:

Any Forms Required:

Authorised by:

Notes:

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Parent category: Legal