Utility Payment Extension Application

EXTENSION APPLICATIONS MUST BE FILED BY 5PM ON THE LAST DAY OF THE MONTH.

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Date of Request

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Account Number *

CUSTOMER INFORMATION:

UTILITY SERVICE ADDRESS: *

CITY / STATE / ZIP CODE *

PRIMARY APPLICANT NAME (First MI Last): *

MAILING ADDRESS (if different from service address): *

PRIMARY PHONE:

SECONDARY PHONE:

EMAIL ADDRESS: *

ACCOUNT INFORMATION:

AMOUNT OWED: $

REQUESTED EXTENSION DATE: *

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Indicate the date you are requesting an extension to.

PREVIOUSLY APPLIED FOR EXTENSION: *

Yes

Enter the date you previously asked for an extension. *

HOUSEHOLD INFORMATION:

OWNERSHIP INFORMATION: *

Home owner (or buying)

Renter

INDICATE YEARS AND MONTHS AT THIS LOCATION: *

LIST ALL HOUSEHOLD MEMBERS
Name	Date of Birth
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year
Name	Date of Birth Month Day Year

SOURCE OF INCOME:
List each household member who has received income in the last thirty (30) days.
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received

ASSISTANCE:

These organizations can be contacted for help: Neighborhood Center 512-756-4334 LaCare 512-756-4422 (Wed. & Fri.) Salvation Army 512-756-2128

REASON ASSISTANCE IS NEEDED: *

HAVE YOU EXHAUSTED ALL OTHER SOURCES OF COMMUNITY HELP BEFORE MAKING THIS APPLICATION? *

Yes

WHO HAVE YOU CONTACTED:

CERTIFICATION:

I certify that the information provided is true and correct to the best of my knowledge and belief.

CUSTOMER SIGNATURE: *

Type your first and last name here. By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

DATE OF SIGNATURE: *

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CITY ORDIANCE

ORDINANCE NO. 2002-04 NOW, THEREFORE, BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF BURNET, TEXAS, THAT; Section 110.6, (f) “Current customers experiencing difficulties paying the current utility bill may make written request for accommodations from the utility department prior to disconnection to permit 20 additional days to pay the current utility account provided the customer has not made such a request in the past 12 months, enters an agreement to pay the full sum within not more than 20 days, and demonstrate one of the following: (1) The customer has a medically needy individual in the residential household and the customer needs additional time to secure the financial resources; or (2) The utility bill was more than 25 percent greater than the highest bill in the last 12 months and the customer needs additional time to secure the financial resources. Only the city manager may approve the agreement.”

Supporting Documents

Utility Payment Extension Application (204 KB)

Utility Payment Extension Application

Supporting Documents

Contact Information