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2. COVID-19/ FINANCIAL HARDSHIP UTILITY REPAYMENT REQUEST
   The repayment plan allows customers additional time to pay their utility balance as a result of financial hardship from the COVID-19 pandemic. The customer will determine a repayment plan that is sustainable and affordable. Depending upon individual circumstances, customers can pay balances in as little as 6 months or up to 24 months. All payment plan related balances and future bills must be paid on time and in full.
4. Date of Request*
   Date of Request
5. Delinquent Balance Due*
7. Water/Sewer Account Number *
9. Name*
11. Service Address*
13. Phone*
14. Email*
16. Repayment Options
    Select a payment installment schedule and list the amount you are able to pay in accordance with the timeframe chosen. Repayment plans must be paid in full within 24 months of this request.
18. Payment Installment Schedule (select only one)*

    1. Weekly (Payment every week by Friday)
    2. Bi-Weekly (Payment on the 1st and 15th)
    3. Monthly (Payment by the 30th)
19. Payment Amount*
21. Payment Start Date*
    Payment Start Date
22. Anticipated Payment End Date*
    Anticipated Payment End Date
24. Comments/ Special Requests
26. Attest*

    I attest I have experienced financial hardship due to the COVID-19 Pandemic and acknowledge acceptance of the payment terms as I have requested above. I agree I must pay the repayment plan related balances and future bills on time and in full. If I am unable to comply with the agreed upon repayment plan, I will immediately contact the Town to renegotiate the terms of my arrangement. I am aware that if I do not comply to the Repayment Plan or pay my current bills, my service could be disconnected.

    1. Yes
28. Town Staff Follow Up
    Town Staff will review and process your request and follow up via email with confirmation of the Repayment Plan.
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field