Form C-718 (03/2017) REQUEST FOR PAYMENT AGREEMENT To: Regional Audit Supervisor Tradename: Address: City: Mail Address: City: Personal Guarantors(s): 1. Name of Individual/Institution Address City/State/Zip Code From: Zip Code: Zip Code: 2. Name of Individual/Institution Address City/State/Zip Code Audit No. to Of this amount, of the above described permit, covering the period from established delinquent fees in the total amount of has been paid leaving a balance of We have applied to at least two different lending institutions located in the State of Texas for a loan to pay the balance. Each has rejected our application. Therefore, we are filing this "Request for Payment Agreement" for the Commission's consideration. We understand this is only a request and that the Commission may accept or reject the request in part or in its entirety. Attached for your consideration are: 1. Form C-717 Overview to Request For Payment Agreement. 2. Notarized copies of the loan application presented to: Name of Financial Institution Name of Financial Institution 3. Loan refusal letters from said institutions 4. Payment Agreement Permit Officer Date Permit Officer Date Name of Individual Name of Individual Signaturer Date Signature Date American LegalNet, Inc. www.FormsWorkFlow.com