Payment Guarantee Moa Template

MEMORANDUM OF AGREEMENT
KNOW ALL MEN BY THESE PRESENTS:
This Agreement made and entered into by and between:
___________________, with business

address located at ___________ and represented
herein by its __________, _____________,
hereinafter referred to as the FIRST PARTY
-and-
______________, of legal age, and

_____________, of legal age, whose place of
residence is at ________________, being ___ and
____, respectively, of the ____,
_________________, hereinafter referred to as the
SECOND PARTY;
-and-
___________________, with business

address located at _______________ represented
herein by its
________________,___________, herein
referred to as the THIRD PARTY
1
WITNESSETH THAT:
WHEREAS, the Second Party has an existing obligation to the

First Party to settle the aforenamed patient’s hospital bill including
professional fees currently amounting to
_______________________ as of _________ as running balance
because the patient is still hospitalized;
WHEREAS, the Third Party certifies that the aforenamed patient

maintains a savings account with the ______________, __________
and it has an available balance amounting to __________________;
WHEREAS, the Second Party undertakes to utilize the

aforementioned savings account deposit with the Third Party to pay the
full amount of their Final Billing upon the discharge of the patient from the
hospital. The Second Party undertakes to deliver and settle the total
billing amount to the First Party upon the discharge of the patient
through a Manager’s Check that will be issued by the Third Party utilizing
the deposited amount of the patient in their branch;
WHEREAS, the Third Party guarantees that a Manager’s Check

amounting to the Total Bill will be issued to the First Party upon the
discharge of the patient and this arrangement is with the full knowledge
and consent of the Second Party as wife and son of the patient and
considering that the patient is presently incapacitated to give his consent
due to his medical condition;
2
WHEREAS, the First Party, in its goodwill, agrees to open the
running hospital account of the patient for hospital charges including
medicine, supplies, services and procedures while the patient is being
treated in the ICU and since he is unable to provide authorization for
withdrawal from his aforementioned bank account.
NOW THEREFORE, for and in consideration of the foregoing

premises, the PARTIES hereto agree to execute this Memorandum of
Agreement subject to the terms and conditions as follows:
1.1 Representation
The THIRD PARTY fully knows and warrants that the FIRST and
SECOND PARTY in this agreement have agreed to a payment plan to secure
any deficiency in the payment of the hospital bills of the patient in the form
of a Manager’s Check to be issued by the patient’s depository bank (Bank of
the Philippine Islands) in favor of the FIRST PARTY upon the discharge of
the patient. The SECOND PARTY shall not make any withdrawal to the said
account and the same shall be reserved for the execution of the payment
plan. Only after the full payment is made to the FIRST PARTY when the
THIRD PARTY may deliver the excess amount of deposit, if there is any, to
the Second Party.
2.1 Payment Plan

The Parties hereby agree to the payment plan, which is the issuance
of a Manager’s Check from the patient’s savings account deposit with
3
Reference No. 8R086720220131001 upon the patient’s discharge. The
SECOND PARTY fully conforms to the THIRD PARTY for the issuance of
the said Manager’s Check as payment to the FIRST PARTY of the amount of
the Total Bill upon final accounting.
3.1 Payment Method

Payment shall be made to the FIRST PARTY in accordance with the
mode as indicated in the Payment Plan. Nevertheless, the SECOND PARTY
may choose to make another mode of payment to the FIRST PARTY for the
settlement of their obligation at any time before the patient is discharge.
4.1 Acceleration Clause

If the SECOND PARTY fails to make full payment of the Total Bill
upon the discharge of the patient, the full amount of the deficiency shall
become due and demandable. This failure shall give rise to the right of the
FIRST PARTY to demand for interest and damages from the SECOND
PARTY.
5.1 Agreement Modification

No modification of this Agreement shall be considered valid and
effective unless made in writing and agreed upon by all Parties.
6.1 Annex
The following annex is hereby incorporated as of this Memorandum of
Agreement:
4
a. Annex-“A” – Bank Certification of Deposit with Reference
____________ issued by the Third Party
IN WITNESS WHEREOF, the Parties herein have hereunto affixed

their signatures to show their conformity this _____ day of _________at
_________________.
______________________
By:
_________________
______________
_______________________
______________
By:
______________
___________
-and-
_________________
______
________________
By:
___________
5
______________
ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)

____________ ) S.S
x- - - - - - - - - - - - - - - - - - - - - - - - - - x
BEFORE ME, on the same date and place personally appeared the following
with their respective identification cards as competent proof of identity:
Name ID Number Expiry Date
known to me and to me known to be same persons who executed the foregoing

document and who acknowledged to me that the same is their free and voluntary act
and deed.
This document consists of seven (7) pages including the page where the notarial
acknowledgment is written.
Witness my hand and the seal of my office.
Doc. No. ____;

Page No.____;
Book No. ____;
6
Series of ____.
ANNEX- “A”

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MEMORANDUM OF AGREEMENT

KNOW ALL MEN BY THESE PRESENTS:

This Agreement made and entered into by and between:

___________________, with business

______________, of legal age, and

___________________, with business

WHEREAS, the Second Party has an existing obligation to the

WHEREAS, the Third Party certifies that the aforenamed patient

WHEREAS, the Second Party undertakes to utilize the

WHEREAS, the Third Party guarantees that a Manager’s Check

NOW THEREFORE, for and in consideration of the foregoing

2.1 Payment Plan

3.1 Payment Method

4.1 Acceleration Clause

5.1 Agreement Modification

IN WITNESS WHEREOF, the Parties herein have hereunto affixed

REPUBLIC OF THE PHILIPPINES)

Name ID Number Expiry Date

known to me and to me known to be same persons who executed the foregoing

Witness my hand and the seal of my office.

Doc. No. ____;

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