Delinquent Account Form

Code IV; §11 of the Chapter Codes states that each chapter may submit to the Executive Vice President, the names of those individuals who have documented, unresolved, outstanding debts to the chapter. The Executive Vice President shall then provide notice to each delinquent member that failure to submit full payment for his unresolved debt within thirty (30) days will result in his expulsion from the Fraternity.

Delinquent accounts are sent within the first five (5) business days of each month.

Chapter: *

School: *

Date * +

Debtor Information Below

First Name *

Last Name *

Street Address *

Address Line 2

City *

State/Province *

Zip Code/Postal Code *

Phone Number *

Email Address *

Balance Due: *

Membership Status: *

Alumnus

Undergraduate

Chapter Advisor First and Last Name *

Chapter Advisor email *

Notes

Any questions about this account will be directed to the chapter treasurer.
Individual payment plans can only be made between the individual and the local chapter.
Submitting this report has no affect on a chapter’s ability or decision to turn an account over to a professional collections agency.
Any payments made will be credited to the chapter’s account within the Fraternity.
Should the delinquent member be expelled and later seek reinstatement, the Chapter Codes require that member first resolve this account and then obtain approval of the chapter and the Fraternity’s Executive Vice President.
Delinquent accounts are processed within the first five (5) business days of each month.

Treasurer Signature * 🛈

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Treasurer first and last name: *

Treasurer Email: *

President Signature: *

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President first and last name: *

President Email: *