Payment Agreement
& Personal Information Disclosure
Sussex County Government
Finance Department – Collections Division
2 The Circle
P.O. Box 589
Georgetown, DE 19947
(302) 855-7831
APPLICANT INFORMATION
Full Name: Date of Birth: Social Security Number:
Street Address: City: State: ZIP:
Telephone Number: Cell Number: Email Address:
Employer Name: Phone Number:
Employer Address: City: State: ZIP:
Length of Employment: Current Position: Gross Annual Income:
CO-APPLICANT INFORMATION
Full Name: Date of Birth: Social Security Number:
Street Address: City: State: ZIP:
Telephone Number: Cell Number: Email Address:
Employer Name: Phone Number:
Employer Address: City: State: ZIP:
Length of Employment: Current Position: Gross Annual Income:
CONTACT INFORMATION
Name, phone number, and address of closest relative (not living with you):
TERMS AND CONDITIONS
I agree to make monthly payments in the amount of $__________ beginning __________________________ for a period of _________ months.
During that time, I am responsible for paying in full any future tax or sewer bills on or before the required due date. While in the payment plan, I am
still subject to the Clean Hands Ordinance, preventing new permits/applications while delinquent. Failure to maintain monthly payments or to pay
future bills may result in the agreement being deemed null and void and all balances immediately due. Further, should the property cease to become
my primary residence or if it is determined that the property is not my primary residence, the agreement will be deemed null and void and all balances
immediately due.
Failure to meet the terms and conditions of this agreement may result in Monitions sale or the County may choose to intercept your IRS tax refund
to offset the past due balance.
_____________________________ _________ ___________________________ __________
(Applicant Signature) (Date) (Co-Applicant Signature) (Date)
_____________________________ _________ ___________________________
(Employee Name) (Date) (Department Name)
Office Use Only
Type Account Number
Property Tax
Utility Billing
Utility Permits
Staff ID
Rev. 09/2018
