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2. Today's Date*
   Today's Date
4. First Name*
5. Last Name*
7. Account Number*
8. Email Address*
10. Service Address*
11. Upload clear picture of Driver's License/State ID*
13. Amount Due*
14. Original Due Date*
    Original Due Date

16. AN EMPLOYEE WILL EMAIL YOU YOUR EXTENSION DATE INFORMATION. FAILURE TO PAY THE TOTAL AMOUNT BY 5PM ON THE AGREED UPON DAY MAY RESULT IN DISCONNECTION OF SERVICE, AS WELL AS A $25 SERVICE CHARGE
    
    I understand that extensions are only offered before my disconnection date.
    
    I am aware that I am allowed 2 extensions per calendar year, and that failure to complete the first extension will void eligibility for a second.
    
    I further understand that not paying the full amount by the agreed upon date may result in service being disconnected the following business day. If my service is disconnected, I understand that all amounts due will need to be paid in full before reconnection can occur. Per City Ordinance, the account's deposit amount may be subject to adjustment, to meet current deposit requirements.

    I AGREE TO THE TERMS AND CONDITIONS OUTLINED IN THIS EXTENSION REQUEST

18. Digitally sign by typing your name*
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