2. Payment Agreement Terms
   If a customer is needing to sign an agreement to extend out their past due balance to avoid disconnection, please fill out form below. Please contact Customer Service if you are unaware of the date you can extend your payment to, to find the cycle and route you are billed in, please follow this link and it will provide you with the furthest payment date for your billing area. If the agreement will not be accepted, you will be contacted by the Customer Service department and they will let you know of your options. As soon as this form is submitted it will bring you to a confirmation page, this is just to confirm that we will get this request, this DOES NOT mean your agreement will be approved, you will receive notification from Customer Service.
4. First Name*
5. Last Name*
7. Address *
8. Acct. #
10. Contact Phone #*
11. E-mail Address*
13. Pay on Date*
    Pay on Date

    Pay on Date
15. PLEASE READ
    By signing this agreement electronically, you are agreeing to pay your past due utility balance by the agreed date. Failure to do so, will result in your utilities being disconnected the following business day, promptly at 8am.
17. Electronic Signature (please type full name)*
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field