Hardship Deferral of Tuition & Fees
Payment Arrangement Contract
I currently owe NMIMT a total of $ . These charges consist of the following:
Previous Semester Alumni Loan
Current Semester Other
Deferred Installment Arrangement:
Pay Period (PP)
8 Payments Monthly (MO) 4 Payments
Date
Amount Date Amount
$ $
$ $
$ $
$ $
$
$
$
$
Name Banner ID
Address Phone
City, State Zip Email
I agree to pay my account in full including a non-refundable $25.00 service charge by the end of the
current semester. If the above arrangements are not complied with, I may be subject to administrative
withdrawal and I will remain financially responsible for all charges incurred during the semester
(including any collection fees incurred). I also fully understand that my diploma, grades, completion of
courses and transcripts will be withheld until my account is paid in full. By signing below, I agree to
the terms set forth is this contract.
Student Signature Date
BUSINESS OFFICE USE ONLY
Recommendation by Student Accounts
Student Accounts Approval Date
Reference # Signature Date
Revised 12/07/09
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