SAVANNAH STATE UNIVERSITY
Box 20419
Savannah, Georgia 31404
OFFICE OF THE BURSAR
Telephone 912 358-4044
Facsimile 912 358-3670
PAYMENT AGREEMENT FORM
STUDENT INFORMATION
Name ________________________________________________________
Last
First
MI
SSU ID # ________________________
Address _____________________________________________________________ Apartment _________________
City _________________________________________________ State _______________
SSU Box Number ________________________
Home # (
)
_____
Zip ___________
Email Address __________________________________________
Work # (
) ________________________ Cell # (
Residence Hall __________________________ Room ___________________ Dorm # (
)
__________
) _________________
PARENT INFORMATION
Name __________________________________________________
Address __________________________________________________________ Apartment _____________
City _________________________________________________ State _______________
Zip __________
PAYMENT SCHEDULE
Term _______________
Outstanding Balance $
Payment Start Date
Payment Deadline Date __________________
Weekly Amount $__________ Bi-Weekly Amount $__________ Monthly Amount $_________ Other $___________
AUTHORIZATION
I hereby agree to honor the above payment arrangement. If I fail to comply with the above agreement I will be removed
from registration, and will be unable to receive my diploma, grades and transcript. I understand that I will still be required
to pay this balance and all collection fees. I understand that registration for classes at SSU will create tuition charges and other associated
fees that will be assessed to my student account. By registering for classes at SSU, I understand and agree to the following :

If I fail to pay any charges on my student account, I will be personally responsible for all costs and fees of collection, which may be based on a
percentage up to a maximum of 34% of the debt. If legal action is required to collect unpaid charges on my student account, I understand that
I will be personally responsible for payments of attorney cost and court costs.

I authorize the University and/or their agents and contractors to contact me regarding my student account at the current or any future phone
numbers that I provide, including my cellar phone or other wireless device, using automated telephone dialing equipment or artificial or prerecorded voice or text message.

This agreement is subject to the laws of the State of Georgia, without regard to its conflict or choice of law provisions. I irrevocably consent to
the jurisdiction of the state and federal courts located in Savannah, GA, in any lawsuits arising out of or concerning this agreement, or the
enforcement of any obligations under this agreement, or the enforcement of any obligations under this agreement, including any lawsuit to
collect amounts that I may owe as a result of this agreement.
______________________________________
Signature (Student)
Date
____________________________________
Bursar’s Office
Date
_______________________________________
Signature (Parent)
Date