Budget Billing Form

Name*

First Last

Account Number*

Applicant Consent*

I hereby verify the above information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.

To qualify for Budget Billing, the follow criteria must be agreed to:

1. The consumer must have at least one year of billing history on the account to be eligible for budget billing.

2. The consumer agrees that each monthly payment will be made by the due date as indicated on the bill. If payment is delinquent more than twice in a twelve month period, the consumer will be removed from the budget payment plan.

3. The consumer understands that the monthly budgeted payment is not the actual amount of electricity used during the billing cycle.

4. Upon termination of the budget billing plan, or if the service is disconnected, the consumer will be liable for any balance due or will be reimbursed for any credit accumulated on the account.

By checking this box and typing my name below, I am submitting my legal, electronic signature that is valid and binding.

Member Electronic Signature (Full Name)*