CHROMEBOOK DAMAGE of FINES LPMS Payment Form 22-23

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Please complete this Form for any payment for LPMS. Email address is collected so that a copy of this form can be emailed. You will also be emailed a receipt for payment from Payezzy. A 3% convenience fee will be charged for this transaction.

Email *

Student's LAST name *

Student's FIRST name *

What is the payment for? Select all that apply *

Damage to Chromebook

Lost Charger

Other:

Required

Optional - Notes

PLEASE NOTE: You MUST click on the link in the FORM CONFIRMATION MESSAGE after you click SUBMIT, or you will NOT actually make a payment. *

I understand I must click on the link AFTER this page to make payment. (Link will be on the screen once you click SUBMIT.)

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A copy of your responses will be emailed to the address you provided.

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