3. 
   

7. COVID-19 ASSISTANCE REQUEST FORM
   If you are having a hard time making payments due to Covid-19, the City can offer a short-term payment plan. Please complete and submit this form to request a payment plan. Only submit one request for assistance per account.
9. Account Number
11. First Name*
12. Last Name*
14. Service Address*
16. Phone Number*
17. Email Address*
19. I am a tenant at this property
21. Failure to provide Owner/Property Manager contact information will delay and possibly deny your request for assistance.
23. Owner/Property Manager Name
25. Owner/PM Phone Number
26. Owner/PM Email Address
28. Terms and Conditions
    The water/wastewater account is three (3) or more months in arrears and is residential property.
30. No late fees or service charges will be charged to the water/wastewater account for the duration of the payment plan unless a payment is not received by the due date.
32. Automatic payments will be suspended until the payment plan has been satisfied. It is the customer's responsibility to request reinstatement of automatic payments.
34. Length of payment plan for rental properties will require approval by the landlord.
36. Failure to keep terms of the payment plan will result in cancellation of the payment plan, water service disconnection, and non-payment charge accessed. The total past due balance will need to be paid in full before service will be reinstated.
38. A property lien may be recorded with Broward County if the payment plan is not satisfied within the specified time frame.
40. I acknowledge that I have read and agree to the Terms and Conditions for the payment plan including details on automatic payments I may have set up and actions I may need to take.
42. I certify my delinquency is due to a hardship caused by COVID-19. Check the appropriate box.
44. I was furloughed.
45. I was laid off.
46. My hours worked were reduced.
48. Other answer:
50. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
52. Electronic Signature
54. For Office Use Only:
    Cycle ____________________ Balance Due $ __________________________
56. Pay Plan Start Date ___________________ Pay Plan Amount $_________________
58. Approved By: ____________________________ Date Entered: _____________________
60. Automatic Payments Cancelled ___________ Landlord Approval received _______________
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field