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2. Name:
4. Address:
6. Daytime Phone Number:
7. Account #:
9. I am requesting an extension of time for the payment of my water bill due:
   I am requesting an extension of time for the payment of my water bill due:
11. THIS APPROVED FORM WILL EXTEND THE PAYMENT DATE TO A DATE NOT LATER THAN 7 DAYS FROM THE DATE SHOWN ON THE DISCONNECT LETTER. ONLY ONE EXTENSION WILL BE GRANTED EACH MONTH.
13. Bill Amount:
14. I agree that the bill amount entered will be paid in full no later than 7 days past due date.

    1. I Agree
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

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