Application for Payment Plan

Date:*field type date
Account Number:*field type single line
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Applicant Name:*field type single line
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Address Number:*field type single line
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Street Name:*field type drop-down
Mailing Address same as Street Address?*field type radio button
Mailing Address same as Street Address?YesNo
Mailing Address:field type single line
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Phone Number:*field type single line
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Email:*field type email
I, , have been financially impacted and request a flexible payment plan. I understand that if my balance is $800 or less, the maximum number of months I can make payments is six (6). If my balance is over $800, I can extend the payments up to twelve (12) months.

Payment Calculation:

Payments are due by the 26th of each month. No bill will be sent for this payment.
Payments are in addition to the regularly accrued charges for the account.
Late penalties will not be assessed if all agreed upon payments are made on time.
Late penalties will be applied if payments are not made according to the agreement.
I understand, should I default on the flexible payment plan as agreed, City of Port Orchard may discontinue utility service and service will not be restored until the balance is paid in full plus any disconnect and reconnect fees. I further understand that should I default on this agreement; City of Port Orchard will not allow another payment plan. All subsequent billings are payable when due.
Property Managers are not eligible for payment plan arrangements.
Applicant Signature:*field type signature
Date:*field type date
The owner recognizes by allowing the tenant to enter into an agreement that utility bills are the ultimate responsibility of the property owner and if the tenant defaults, amounts due will become the responsibility of the owner.
Property Owner (if applicable):field type single line
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Phone:field type single line
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Date:field type date

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