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Financial Statement Form

If you meet certain income requirements, you may be eligible for special payment agreement terms.

Thank You for Submitting Your Eligibility Form

We are reviewing your information and will contact you as soon as possible. Please allow us approximately 30 days to complete our review. Filling out the form does not guarantee eligibility. If you have any questions, please contact us.

Thanks for Your Submission

Unfortunately, you do not qualify for a special payment agreement because your expenses are greater than you income. If you believe this is inaccurate, please resubmit the form.

Need help getting your bills back on track? Youy may be eligible for a standard payment agreement or one of our other assistance programs.

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Your form could not be submitted.

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