OES Billing: Split Account Request

Request to Split Billing

Student First Name: *

Student Last Name *

Current Grade *

As parents of the above named student, we request the tuition billing be split as described below. We understand that only the tuition can be split and that one parent will be responsible for the incidental charges throughout the school year.

Parent (A) Name *

Parent Email Address *

Percentage or amount of tuition that Parent (A) is responsible for: *

Parent (B) Name *

Parent Email Address *

Percentage or amount of tuition that Parent (B) is responsible for: *

Incidental Billing Charges for this student should be billed to: *

By typing my name below, I acknowledge that I have discussed this arrangement with the other parent named on this form. We understand that OES will divide tuition between our accounts as indicated above. OES cannot divide incidental charges between our accounts in FACTS, and we agree to work out our own arrangements for splitting these charges. We agree that the parent noted above is responsible for paying OES for all incidental charges. This agreement will remain in effect until we notify OES and submit a new form for this student.

Parent Signature *