Private Pay Agreement
Professional Private Pay Agreement template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Private Pay Agreement
TEMPLATE • Inspection-Ready AFH Standard
1. Base Room & Board Rates
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Tiered Level-of-Care Fees
FINANCIAL TERMSBase 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.
3. Late Charges, Returned Check Fees & Refunds
Provider Signature / Date
Resident / POA Signature / Date
Purchase to Unlock Full Document
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Document Section Breakdown (4 Sections)
Base Room & Board Rates
Monthly payment terms, due date, billing cycle, and deposit requirements.
Tiered Level-of-Care Fees
Adjustments based on care level changes, incontinence supplies, and special diets.
Late Charges, Returned Check Fees & Refunds
Grace periods, financial penalties, and pro-rated move-out calculations.
Financial Guarantor Signatures
Responsible party, POA, or guarantor legal signature block.
Or get this form included in the AFH Starter Kit ($129)