2. UTILITY BILLING AGREEMENT

4. Account Holder Name (as it appears on the bill)*
5. Date
   Date
7. Service Address:*
8. Phone Number:*
10. Email Address*
11. Account Number:
13. Check box below if you need more time.

    1. I just need extra time to pay the total balance on my account.
14. I can pay my total balance on this date:
    I can pay my total balance on this date:
16. Check below if you can't pay your balance in full at once. You will need to pay future bills and an installment amount.

    1. I need to split up my total balance over time.
17. Please enter the amount you can afford to pay a month in addition to your regular monthly bill.

19. I agree to pay The City of Daytona Beach Utility Billing Department the installment payments as specified in the agreement I am requesting.  I understand that it is my responsibility to pay my monthly utility bill (including installment amount from this agreement) no later than the due date noted on the agreement. Should I not pay my monthly bill in full, I understand my account is subject to penalty fees and disconnection of service until the account is brought current.

    By submitting this form you are requesting a customer service representative contact you to discuss the terms of a payment plan. The payment plan agreement does not go into effect until confirmed by a customer service representative. 

21. Electronic Signature Agreement

    1. I agree.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

22. Customer Signature:*

    
    

    
    

24. Are you requesting this payment plan arrangement of behalf of someone else?

    1. Yes, I am requesting a payment plan arrangement on behalf of the account holder.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field