This document certifies that the proprietor/lien-holder, ___________, and the renter/buyer, ___________, agree to deferment of the payment of $_________ for the month of ___________, 2026.
The deferment is not to exceed _____ months and a penalty of ____% ($________) is assessed for the deferment.
Should the renter/buyer default on this agreement actions as defined in the original lease/purchase contract will be exercised at the discretion of the proprietor/lien-holder.

Proprietor/Lien-holder signature: _________________________ date: ______________