Residential Payment Agreement

Customer Name: _____________________________________________
Address: _____________________________________________
Account#: _____________________________________________

The total Amount owed to [UTILITY NAME ] for this account as of MM/DD/YYYY is $XX.XX.

[UTILITY NAME] is required to offer a payment agreement that you are able to pay considering your financial circumstances. This agreement should not be signed if you are unable to keep the terms. Alternate terms may be available if you can demonstrate financial need. Alternate terms may include no down payment and payments as low as $10 per month above your current bills. If you sign and return this form, along with the down payment by MM/DD/YYYY you will be entering into a payment agreement and by doing so will avoid termination of service.

Assistance to pay utility bills may be available to recipients of public assistance or supplemental security income from your local social services office. This agreement may be changed if your financial circumstances change significantly because of conditions beyond your control. If after entering into this agreement, you fail to comply with the terms, [UTILITY NAME] may terminate service, as well as seek to suspend your [LDNAME] service. If you do not sign this agreement or pay the total amount due of $XX.XX by MM/DD/YYYY, [UTILITY NAME] may seek to terminate your service. If you are unable to pay these terms, if further assistance is needed, or if you wish to discuss this agreement please call [UTILITY NAME] at 1-800-XXX-XXXX.

Payment of Outstanding Balance:

Your current monthly budget amount is: $XX.XX

If you are not already enrolled in our Budget Billing Program, which allows you to pay for your service in equal monthly installments, and wish to enroll, check the box below and we will start you on our program immediately.

[ ] Yes! I would like Budget Billing

Acceptance of Agreement:

Signature: _________________________________________
Date: _________________________________________

This agreement has been accepted by [UTILITY NAME]. If you and [UTILITY NAME] cannot negotiate a payment agreement, or if you need any further assistance, you may contact the Public Service Commission at 1-800-342-3377.

Return one copy of this agreement signed, with the down payment, by MM/DD/YYYY. If it is not signed and returned, your service may be terminated.

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