2. Requestor's Name*
4. Account Number*
6. Service Address*
8. Phone Number*
10. Email*
12. Installment Term*
    -- Select One --3 Months4 Months6 Months
14. Reason for Request*
    -- Select One --UnemploymentCOVID-19 related illnessOther COVID-19 issue
15. Other*
17. Agreement*

    I hereby certify that I am requesting this payment plan as a result of a COVID-related issue. I agree that I am entering into an agreement to pay my outstanding charges over the period specified in this document. I further agree that I understand that all payment plan payments are due on the due dates of my monthly statements along with current charges for each month until the plan amount is paid in full. I understand that failure to make payments as agreed will result in disconnection of utility services.

    1. Yes, I agree to the statements above.
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

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