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COVID-19 Payment Plan Agreement

  1. Enter the name on the account.

  2. Enter the mailing address for the account.

  3. Enter the service address of the account (where water service is provided; may be different than mailing address).

  4. Enter a phone number where you can be contacted.

  5. Enter an email address where you can be contacted.

  6. Enter the total amount due from your bill.

  7. Divide "Amount of Debt" by 12 and enter that amount here.

  8. Enter the account number.

  9. Agreement:

    The undersigned agrees to pay the "Minimum Monthly Payment" (calculated above) in twelve (12) consecutive installments per month, along with the monthly bill due, until the past due amount is paid in full.

  10. Please include a copy of your Driver's License/ID.

  11. Notice:

    All payments must be received by either the due date or the disconnection date on your bill whichever comes first. If your service is disconnected, you will forfeit your arrangement and will have to pay the entire bill along with an additional $25.00 to have your services re-connected. Late penalties will also be incurred if arrangement is forfeited.

  12. Acknowledgement:

    I hereby acknowledge and agree to the terms of this payment plan.

  13. Account Holder Signature:*

    By checking the "I agree" box below, you agree and acknowledge that 1) your agreement will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  14. Enter today's date.

  15. Leave This Blank:

  16. This field is not part of the form submission.