a Form – Financial Responsibility

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Financial Responsibility

    I, understand that Diversified Monitoring Systems collectsmonitoring fees a month in advance. I agree to make all payments as agreed based on the attached Payment Fee Schedule.
    A missed payment is grounds for non-compliance of your program. Until you are caught up on your payments, DMS personnel cannot write a positive progress report to your attorney or the Court. We are a monitoring agency and thus report all facts relevant to your program at the time the progress report is required.
    Payment for services is due at time of enrollment, unless prior arrangements have been made. No refunds will be issued for clients taken into custody or equipment removed for program violations.
    Refund Policy
    If a clients’ monitoring equipment is removed before completion of month paid for in advance, Diversified
    Monitoring Systems will pro-rate the month and refund the difference.

    • Days credited toward refund will commence upon receiving all equipment issued to client.

    • No refunds will be issued the first month of any DMS program including DUI court

    • All refunds issued by check will be mailed no later than the 5th of the month following removal.


    • No personal checks. Money orders, cashier’s check, credit card, debit card cash accepted.

    • At this time you will need to make separate payments for monitoring fees and treatment fees.

    • You may leave your credit card number on file and MOST will run your card per below checked payment plan.


    2% Service Charge

    A 2% service charge will be added on all credit card transaction. This fee will not apply to cash or money orders. By filling out the below credit card authorization form, you authorize DMS to charge your credit card on or after your enrollment date for your monthly monitoring fees. We will provide a courtesy e-mail with the amount, date, and confirmation number (print this e-mail for your records).

    Credit Card #

    Expiration Date

    3 digit V-code on back of card:


    Monthly amount:



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