Extension Request for Utility Payment

2. Today's Date*
   Today's Date

3. Account #:

5. Name on Account*

7. Service Address*

   Elgin, Texas 78621

9. Phone Number*

10. Email Address*

12. I agree to the following Terms of Extension*

    Check all three boxes

    1. I understand I have 3 extensions per calendar year to use toward my utility bill.
    2. I understand the payment is due on the 1st of the month following the original due date
    3. I understand the balance must be paid IN FULL or the account will be charged a disconnection fee and services will be subject to disconnection
    4. I understand the 10% late fee, for not paying the bill by the 15th of the month, will still be applied to my balance.
14. Customer Signature*

    I understand that by typing my name above I have agreed to the Terms of Extension and authorize the Utility Billing Department to apply an extension to my account for the current billing period.

16. If you would prefer to print this form and submit it to the Utility Billing Department, you may use one of the following methods:

    1. Mail to - PO Box 591, Elgin, TX 78621
    2. Deliver to - 310 N Main Street
    3. Fax to - 512-285-3016

17. 

21. Office Use Only

23. Extension Granted

    1. Yes

    1. No

24. # of extensions remaining for the Year

Leave This Blank:


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

    This field is not part of the form submission.

29. Submit

* indicates a required field