Payment Arrangement

Payment Arrangement
Please note:

Arrangements are not guaranteed. Arrangements will be accepted or denied by email response. Failure to pay arrangement by due date date will result in a $50.00 Non-Payment fee (1st time) $75.00(each subsequent) and/ or disconnection of service. This fee will be applied at 8 a.m. following the due date of the arrangement if agreement is not fulfilled. Only one extension is allowed per Quarter. Quarters are as follows:

1st Quarter January, February, March

2nd Quarter April, May, June

3rd Quarter July, August, September

4th Quarter October, November, December

There will be no exceptions to this policy.
Account #
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date arrangement is requested on:*

MonthDayYear
Date
Payment to be made on: Date cannot be more than 7 days from the 6th*

MonthDayYear
Date
Reason for arrangement:*
Signature*

Clear
Should be Empty: