Enter your BWA account number.
Enter the name on this BWA account.
Enter the service address for this account.
Enter the phone number where we can contact you if there are questions about this Payment Extension.
Please enter the payment amount that you are requesting an extension for. This amount should include any past due amounts on your account.
Please enter the date you will make this payment.
I request an extension for the amount entered above and will pay this amount on the date indicated above. I understand that if I do not make this payment that my water service may be interrupted until the account is paid in full, including all applicable reconnect charges.
By checking the "I agree" box above, you agree and acknowledge that 1) your payment extension 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.
This field is not part of the form submission.
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