Request for Payment Plan under Hardship Cases

To request a Payment Plan under Hardship Cases, download and submit the attached PDF or fill out the form below.

DOWNLOAD PDF: Request for Payment Plan under Hardship Cases

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Acknowledgment (Signature) Please Select One

I acknowledge that according to District Resolution 2019-11 (District Code 6.08.010, if I am approved for a payment plan and I am delinquent on my current charges for more than 60 days, my water service may be discontinued.

i. Certification of Primary Care Provider

Customer has provided Certification of a Primary Care provider in accordance with Welfare and Institutions Code 14088(A)(1)

ii. Demonstration that the Customer is Unable to Pay with the normal billing cycle.

Customer acknowledges under penalty of perjury, by checking this box and signing this form, that they have a financial inability to pay and they agree to enter into a payment plan. Customer acknowledges that their water service can be turned off if they do not pay their current residential service charged for 60 days or more.

iii. Willingness to Enter into an Amortization Agreement, Alternative Payment Scheduled, or a Plan for Deferred Payments.

Customer acknowledges they are willing to enter into a payment plan not to exceed 12 months.

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