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2. Water Account Billing Cycle*

   Please select the range below that includes the first 3 numbers in your BWA account number.

   1. 001 - 007 (Cycle 1)
   2. 013 - 020 (Cycle 2)
   3. 021 - 028 (Cycle 3)
   4. 030 - 042 (Cycle 4)
   5. 050 - 052 (Cycle 3)
   6. 090 - 092 (Cycle 4)
4. BWA Account Number*
   Enter your BWA account number.
6. Account Name*
   Enter the name on this BWA account.
8. Service Address*
   Enter the service address for this account.
10. Phone number*
    Enter the phone number where we can contact you if there are questions about this Payment Extension.
12. Your Email Address*
14. Cycle 1--Your extension due date is December 13. If you need more time than this to pay your bill you must contact our office at 817.249.1250 or billing@benbrookwater.com.
16. Cycle 2--Your extension due date is December 20. If you need more time than this to pay your bill you must contact our office at 817.249.1250 or billing@benbrookwater.com.
18. Cycle 3--Your extension date is December 23. If you need more time than this to pay your bill you must contact our office at 817.249.1250 or billing@benbrookwater.com.
20. Cycle 3--Your extension date is December 23. If you need more time than this to pay your bill you must contact our office at 817.249.1250 or billing@benbrookwater.com
22. Cycle 4--Your extension date is December 29. If you need more time than this to pay your bill you must contact our office at 817.249.1250 or billing@benbrookwater.com.
24. Cycle 4--Your extension date is December 29. If you need more time than this to pay your bill you must contact our office at 817.249.1250 or billing@benbrookwater.com.
26. Amount of Payment*
    Please enter the payment amount that you are requesting an extension for. This amount should include any past due amounts on your account.
28. Request for Payment Extension
    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.
30. Electronic Signature*

    1. I agree

    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.
32. Electronic Signature*
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field