Customer Payment Agreement

2. This Utility Bill Payment Extension Agreement is entered into between Pelham Water Works and the following customer:
4. Customer*
5. Date*
   Date
7. Phone*
9. The agreement is as follows:
11. Account #*
13. Date Bill was Due*
    Date Bill was Due
14. Extended Due Date*
    Extended Due Date
15. Account Balance Due*
17. Address*
19. City*
20. State*
21. Zip Code*
23. Acknowledgement*

    Signed agreements must be received in our office before the close of business (4:00 p.m.) the day before scheduled disconnects. No agreements will be accepted or made on the day of disconnects. The customer understands that payment extensions are limited to three extensions per year, and extensions cannot exceed 14 calendar days from the original disconnect date. The customer agrees to pay the entire account balance due at the time of agreement by the close of business (4:00 p.m.) on the above extended due date. NO EXCEPTIONS

    The customer acknowledges that failure to pay the entire account balance before 4:00 p.m. will result in immediate disconnection of services plus a $100.00 disconnect fee added to the account. For same-day reconnection, the entire account balance, including the disconnect fee, must be paid in full before 3:00 p.m. If full payment is made after 3:00 p.m., services will be restored the following business day. 

    **If you do not receive a confirmation that your agreement was received, please contact our office at 205.620.6420 during normal business hours to confirm receipt of the agreement request.**

    The City of Pelham does not provide or restore water service to an existing property with an unpaid balance.

    Follow this link to read important general information about utility service.

    1. I acknowledge, understand and agree to all terms listed above.
25. Electronic Signature*

    This electronic signature is intended to be the legally binding equivalent of a handwritten signature. By signing electronically, you acknowledge and agree that your electronic signature carries the same legal weight, validity, and enforceability as a traditional handwritten signature under applicable laws and regulations, including the U.S. Electronic Signatures in Global and National Commerce Act (ESIGN Act) and the Uniform Electronic Transactions Act (UETA).

    If you do not wish to sign electronically, please contact us for alternative signing methods.

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field