Utility Payment Extension Application

EXTENSION APPLICATIONS MUST BE FILED BY 5PM ON THE LAST DAY OF THE MONTH.

form.antibot { display: none !important; } You must have JavaScript enabled to use this form.

Date of Request

edit-submitted-date-of-request-month

edit-submitted-date-of-request-day

edit-submitted-date-of-request-year

Account Number *

CUSTOMER INFORMATION:

UTILITY SERVICE ADDRESS: *

CITY / STATE / ZIP CODE *

PRIMARY APPLICANT NAME (First MI Last): *

MAILING ADDRESS (if different from service address): *

PRIMARY PHONE:

SECONDARY PHONE:

EMAIL ADDRESS: *

ACCOUNT INFORMATION:

AMOUNT OWED: $

REQUESTED EXTENSION DATE: *

edit-submitted-account-information-requested-extension-date-month

edit-submitted-account-information-requested-extension-date-day

edit-submitted-account-information-requested-extension-date-year

Indicate the date you are requesting an extension to.

PREVIOUSLY APPLIED FOR EXTENSION: *

Yes

Enter the date you previously asked for an extension. *

HOUSEHOLD INFORMATION:

OWNERSHIP INFORMATION: *

Home owner (or buying)

Renter

INDICATE YEARS AND MONTHS AT THIS LOCATION: *

LIST ALL HOUSEHOLD MEMBERS
Name	Date of Birth
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year

SOURCE OF INCOME:
List each household member who has received income in the last thirty (30) days.
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received

ASSISTANCE:

These organizations can be contacted for help: Neighborhood Center 512-756-4334 LaCare 512-756-4422 (Wed. & Fri.) Salvation Army 512-756-2128

REASON ASSISTANCE IS NEEDED: *

HAVE YOU EXHAUSTED ALL OTHER SOURCES OF COMMUNITY HELP BEFORE MAKING THIS APPLICATION? *

Yes

WHO HAVE YOU CONTACTED:

CERTIFICATION: (La CERTIFICACION))

I certify that the information provided is true and correct to the best of my knowledge and belief. (Certifico que la información proporcionó es verdad y correcto al mejor de mi conocimiento y la creencia.)

SIGNATURE: (La Firma del solicitante) *

Type your first and last name here.

DATE SIGNED: (Fecha) *

edit-submitted-certification-date-signed-month

edit-submitted-certification-date-signed-day

edit-submitted-certification-date-signed-year

Supporting Documents

utility_payment_extension_application.pdf (345 KB)

Utility Payment Extension Application

Supporting Documents

Contact Information