Payment Plan Program

Program Level/ Degree*

Student Type:*

Half balance

1/4 balance

Due Date

Second Due

Final Date

Student Name:*

First NameLast Name

Student ID#*

Student Email:*

example@example.com

Payment Option:*

Pay your balance in full by the due date:Choose a payment plan:

Payment Plan*

Pay in two payments. Plus $100 feePay in three payments. Plus $200 fee.

Option1:

Option 2:

Option 3:

Please communicate with the Student Financial Services team if you have difficulty making a payment. By checking the boxes below, I acknowledge that:*

The University is extending me a line of credit by allowing me to make payments over time. I will meet all the guidelines set forth by the payment plan.I am entering into a financial payment plan with the University of the Potomac.Failure to make the payment by the due date will result in a $100 late fee.Failure to make a payment by the due date, could impact my ability to make another payment plan for one semester.This estimate may change based on scholarship or discount eligibility.

If you have any questions about the payment plan program, please contact the Student Financial Services department at studentfinancialservices@potomac.edu

Important: Pursuant to Section 155 of the Higher Education Act of 1965, as amended, (HEA) and to satisfy the requirements of Section 128(e)(3) of the Truth in Lending Act, a lender must obtain a self-certification signed by the applicant before disbursing a private education loan. The school is required on request to provide this form or the required information only for students admitted or enrolled at the school. Throughout this Applicant Self-Certification, “you” and “your” refer to the applicant who is applying for the loan. The applicant and the student may be the same person.

I have read, understand, and agree*

Accept

Student Signature*

Date

Office Use Only:
Student Financial Services: __________________________________ Date:_____