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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Email Address*
14. Account Number*
16. Payment Amount (Enter the amount given to you by Town Staff. If you have not contacted Town Staff, do not complete this form until you are given your payment amount.)*
18. Payment Plan Terms & Conditions
    Customers shall be provided the opportunity to make a reasonable payment plan to pay off over a ten (10) month period any accumulated charges during the effective period*. It is solely the customers responsibility to request a Payment Plan. The Payment Plan will be divided into 10 equal payments. No late fees shall be charged, and no termination of service will occur while a written and signed payment plan is active and in good standing. Payment plans do NOT cover new monthly bills, charges, fees, etc. and all new bills are due and payable on or before the due date are subject to late fees and termination of service. New bills not paid on or before the due date are subject to late fees and termination of service. Payment plans will automatically cancel if payment installment AND/OR current bills are not paid on or before the due date(s). This terminates the payment plan; it will no longer be active and in good standing. Failure to make the scheduled payments for a Payment Plan will result in the Payment Plan being declared null and void and the customer will become subject to late fees and termination of service for the unpaid balance of charges incurred after the Plan ends. No provision of the Executive order shall be construed as relieving a customer of their obligation to pay bills for receipt of any service covered by this Executive Order.
20. Type Your Name
    By typing my name in this box, I agree to the terms and conditions in this agreement. I understand that my first payment for the plan is due on September 20, 2020.
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22. 1. Receive an email copy of this form.
23. Email address

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