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2. Payment Arrangement (for Heat Related Events Only)

   I hereby agree to the following payment arrangement:

4. First Name*
5. Last Name*
7. Service Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Customer Number (if known)
16. Email Address
18. I agree to pay the past due balance of $:

    (Final total amount due will be determined by Woodinville Water District Staff)

20. Payment arrangement end date:
    Payment arrangement end date:

    (no later than May 15th of the following year)

21. Today's Date
    Today's Date

23. By submitting this request, I acknowledge that I will apply for a payment arrangement agreement.

    District Staff will contact you to confirm the past due balance amount.

    District Staff is authorized to offer a payment arrangement during heat-related weather events.  This agreement is a "promise to pay" the past due balance in full before May 15th of the following calendar year (at the latest).  This is a one-time agreement and no late fees or shut off fees will be applied to the past due bill(s) covered in the above referenced payment arrangement during the payment arrangement period as long as the terms are being met.  This agreement must be in place in order for your water to be turned back on..

    If the past due payment is not received by the above end date your water will be disconnected immediately.

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

    This field is not part of the form submission.

29. Submit Submit and Print

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