Form | Late Payment Waiver

Late Payment Fee Waiver Request

Waiver Request For:(Required)

Late Payment

Application Fee

Member ID #(Required)

Full Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

A. Have you requested a previous waiver of late fee?(Required)

Yes

B. Were you assessed the late fee due to circumstances such as illness or death in the family?(Required)

Yes

Explanation:(Required)

Please Note: A one-time waiver will be granted upon approval. Any future waiver will require approval from the Board of Directors.

Signature(Required)

Date(Required)

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