Application for Pandemic Deferred Payment Plan

Date

Account Number*

Location*

Own Home Renter (if renter owner must agree with terms)

Applicant Name (must be legal account holder)*

First Name Last Name

Phone Number*

Please enter a valid phone number.

Email

Date of Birth*

Social Security #

Mailing Address (if different than location above)

Street Address

City, State Zip

Explain Other / Additional Information

Terms and Conditions:
• Payments are due by the last day of each month. A separate bill will not be sent for this payment.
• Payments are calculated to include the regularly accrued charges for the account.(based on account history and terms of agreement)
•Late penalties will not be assessed and door notices will not be delivered if all agreed upon payments are made on time.
•Late penalties will be applied and door notices will be delivered if payments are not made according to this agreement.
•Property Owners and/or Property Management Companies (PMC) must complete the request on behalf of their tenant(s) both signatures must be on file.
•I understand, should I default on the flexible payment plan as agreed, the City of Fircrest may discontinue utility service and service will not be restored until the past due balance is paid in full plus any disconnect and reconnect fees. I further understand that should I default on this agreement, the City of Fircrest will not allow another payment plan.

I understand that my application is no guarantee of any assistance being awarded to me through this program.

Applicant Signature*

Clear

Date