Utility Payment Extension Form

2. 

3. Utility Payment Extension Form

5. Date*
   Date

7. First Name*

8. Last Name*

10. Address1*

12. Address2

14. City*

15. State*

16. Zip*

18. Phone Number*

19. Driver's License #*

21. Account Number

22. Past Due Amount

24. Current Amount

25. Total

27. E-mail address

28. Reason for Request*

30. PAST DUE AMOUNTS MUST BE PAID BEFORE THE 15TH OF THE MONTH. I AGREE TO PAY MY BILL AS FOLLOWS:

    PAST DUE AMOUNTS MUST BE PAID BEFORE THE 15TH OF THE MONTH. I AGREE TO PAY MY BILL AS FOLLOWS:

32. Past Due Amount*

33. Date I Agree to Pay*
    Date I Agree to Pay

35. I understand that by submitting this form, I have relinquished my rights for any further delinquent notification and that future notices will not relieve me of these arrangements. I understand that FAILURE TO PAY by the specified date on this form WILL CAUSE THE CITY TO DISCONTINUE MY WATER SERVICE at the specified address on this form. I understand that additional fees will be charged for any water service reconnection. This extension will not eliminate penalties being imposed. A City representative will contact you for additional confirmation.

    I understand that by submitting this form, I have relinquished my rights for any further delinquent notification and that future notices will not relieve me of these arrangements. I understand that FAILURE TO PAY by the specified date on this form WILL CAUSE THE CITY TO DISCONTINUE MY WATER SERVICE at the specified address on this form. I understand that additional fees will be charged for any water service reconnection. This extension will not eliminate penalties being imposed. A City representative will contact you for additional confirmation.

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field