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Payment Extension
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This form has been modified since it was saved. Please review all fields before submitting.
Water Account Billing Cycle
*
Please select the range below that includes the first 3 numbers in your BWA account number.
001 - 007 (Cycle 1)
013 - 020 (Cycle 2)
021 - 028 (Cycle 3)
030 - 042 (Cycle 4)
050 - 052 (Cycle 3)
090 - 092 (Cycle 4)
BWA Account Number
*
Enter your BWA account number.
Account Name
*
Enter the name on this BWA account.
Service Address
*
Enter the service address for this account.
Phone number
*
Enter the phone number where we can contact you if there are questions about this Payment Extension.
Your Email Address
*
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.
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.
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.
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
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.
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.
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.
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.
Electronic Signature
*
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.
Electronic Signature
*
Leave This Blank:
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Email address
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