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Professional Private Pay Agreement template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Monthly payment terms, due date, billing cycle, and deposit requirements.
Adjustments based on care level changes, incontinence supplies, and special diets.
Grace periods, financial penalties, and pro-rated move-out calculations.
Responsible party, POA, or guarantor legal signature block.
Or get this form included in the AFH Starter Kit ($129)