Vehicle Payment Plan

Vehicle assistance payment plan through Moneytalk's general program or a city specific sub-program.

1Tell us about yourself

2Vehicle Information

3Program Acknowledgements

4Payment Information

5Wrap-It Up

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Enter vehicle Make: *

The "make" is the name of the auto maker such as Toyota, Honda, Dodge, Chevrolet, Nissan, etc.

Enter the vehicle's Model: *

The "model" is the specific type of vehicle made by the maker. For example, Civic is a model made by Honda, Maxima is a model made by Nissan, Grand Caravan is a model made by Dodge.

Enter the vehicle's year: *

Models of a vehicle change each year. Which year's model is this vehicle?

Enter the vehicle's VIN (vehicle identification number): *

VIN can be found in multiple places on your vehicle. Easiest places to look are - (1) front windshield commonly in the lower driver's side corner, (2) on the driver's side door jamb sticker, (3) stamped on the vehicle's frame inside the hood

Briefly describe the agreed upon repairs. *

Program Acknowledgements

While this payment plan covers multiple vehicle assistance opportunities, there are some aspects which apply to all of them. Please indicate your agreement to comply with the requirements of the program(s).

Your vehicle will not be returned to you until a significant portion of the repair bill has been paid. *

I understand / Acknowledge
No, I am not okay with this

Your car cannot be returned to you unless full payment of the negotiated price has been made. The negotiated cost may reflect financial contributions from our partners; a reduction in the cost offered by the automotive repair shop; a payment plan so that you can pay for the repairs over time; or a combination of the three.

The payment plan will be followed through to completion. *

I understand / Acknowledge
No, I am not okay with this

If a payment cannot be made as agreed, the customer will email both Moneytalk and the automotive repair shop. *

I understand / Acknowledge
No, I am not okay with this

You will be asked to explain the situation and the plan for moving forward with the payments.

Are you a current Moneytalk financial coaching client? If not, what is your status? (copy) *

Yes
No, this is my first interaction with Moneytalk
No, but I participate in other Moneytalk services

In order to receive vehicle assistance, you are required to meet with a Moneytalk financial coach for a coaching assessment. *

I understand / Acknowledge
No, I am not okay with this

If you are on a payment plan, you must participate in financial coaching until the payment plan is complete. *

I understand / Acknowledge
No, I am not okay with this

They payment plan should be completed within 3 months of the vehicle repair completion. *

I understand / Acknowledge
No, I am not okay with this

If the plan cannot be completed in 3 months, it is possible to work through Moneytalk Financial Foundations to complete the payment plan.

Mark all that apply *

Donated or discounted parts
Donations from friends or family
Donated or discounted labor
Donation from Moneytalk Financial Foundations
Client paid entire remaining balance, Repair bill is paid in full
Donation from sub-program support
Client paid a portion and will be using a payment plan for the remaining balance

Conflicting options were selected. Please correct.

The "Client paid entire remaining balance, Repair bill is paid in full" and "Client paid a portion and will be using a payment plan for the remaining balance" should not both be selected. Only one can be true.

Enter total cost of the repairs (without discounts or donations applied). *

Enter amount of discounted or donated parts. *

Name of the company who donated or discounted the parts. *

Enter amount of discounted or donated labor provided by automotive repair shop. *

Enter amount donated by family or friends. *

Enter amount donated by Moneytalk Financial Foundations. *

Enter amount donated by sub-program support. *

Sub-programs are city resident specific (such as Shawnee Car Care) or other subset of residents or customers.

Select sub-program supporting this vehicle repair.

Enter amount paid by client when vehicle was released. *

Enter amount to be paid through the payment plan. *

Total amount should match "Total cost of repairs" listed above.

$ 0.00

Stripe Credit Card *

Card

Name on Card

The automotive repair shop will attempt to contact you and confirm prior to processing the payment as planned. Entering your information here does not cause the card to be processed at this time. The information is being provided solely for purposes of simplifying the remaining payments.

Wrap-it Up

Anything else you would like for us to know?

Has Moneytalk Financial Foundations executive director, Teresa McGarry, approved the payment plan? *

Yes, this has been approved by MTFF
Not, MTFF did not agree with this payment plan
No, this plan is pending approval by MTFF

Customer signature implies agreement with the payment plan. *

Automotive Repair Shop's representative's signature implies agreement with the payment plan. *

Fillable PDF Version of Payment Plan

Below is a link to a PDF that can be printed or filled out online if you would rather complete the form in this format.

Christian Brothers Automotive – Shawnee

CBAS Payment Plan