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Contact Us
Payment Agreement Form
Payment Agreement Form
.
2024-01-25T16:04:11-05:00
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PAYMENT AGREEMENT FORM
Please complete the following information for the Payment Agreement:
Payment Agreement Number
*
Service Address:
*
Phone #:
*
Email
TERMS AND CONTIDIONS OF MVD PAYMENT AGREEMENT
MVD is providing a Payment Agreement is in lieu of water service disconnection for the service location reflected on the Payment Agreement. Upon establishment of a mutually agreed upon Payment Agreement, late fees will not be assessed and the location reflected on the Payment Agreement will be exempt from water service disconnection. If payment is not received as outlined in the Payment Agreement and/or if a payment is returned as unpaid the Payment Agreement will be voided. A voided Payment Agreement will result in water service disconnection for the service location reflected on the Payment Agreement. A voided Payment Agreement will cause reinstatement of late fee processing and can affect eligibility of future Payment Agreements.
CONFIRMATION AND AGREEMENT
I confirm the following:
I have carefully read the Payment Agreement provided by MVD.
I fully understand the contents and the requirements set forth in the Payment Agreement.
I am aware that the Payment Agreement is legally binding.
I agree to make payment as outlined in Payment Agreement provided by MVD.
I am aware water service can and will be disconnected should the
Payment Agreement be voided.
I agree to the Terms and Conditions of the Payment Agreement.
Name of Person Completing Form
*
Final Approval & Submission:
*
By checking this box I confirm that I understand and agree to the Terms & Conditions as well as the Confirmation & Agreement of the Payment Agreement.
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