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2. Applicant First Name*
3. Applicant Last Name*
5. Parcel Number
7. Property Street Address*
8. Property Unit Number
10. Property City*
11. Property State*
13. Property ZIP Code*
15. Phone*
16. Email*
18. Financial Institution
19. Monthly Payment Amount*
21. Monthly payment to begin*
22. Date to be paid by each month*

24. Failure to comply with this agreement will result in forced collection action against you. In accordance with north carolina general statutes 105-366, 105-367, and 105-368, the county is authorized to take certain actions to effect collection of a debt including garnishment, bank attachment, foreclosure, and seizure of assets. You will be assessed any additional fees and costs incurred by the county to collect this debt.

    No payment coupons will be sent to you to fulfill this agreement. It is the taxpayers responsibility to ensure that these payments are received by the tax office by the due dates agreed upon*

26. I have, to the best of my knowledge, provided complete and accurate information regarding the above information

    1. Yes
28. Signature*
29. Date of Request
    Date of Request
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field