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POVEIEO / 1' ElkRiver <br /> --- <br /> NATURE <br /> POWERED T O SERVE Municipal Utilities Fax:763-441-8099 <br /> Phone:763-441-2020 <br /> Payment Arrangements <br /> Name: Address: <br /> Phone: Account#: <br /> **Social Security# **D.O.B <br /> *** HIGHLIGHTED AREAS MUST BE FILLED OUT IN ORDER TO BE VALID** <br /> Amount $ Date Amount $ Date <br /> Amount $ Date Amount $ Date <br /> Amount $ Date Amount $ Date <br /> Amount $ Date Amount $ Date <br /> Amount $ Date Amount $ Date <br /> Amount $ Date Amount $ Date <br /> Upon signing this form, you the customer are responsible for making the payments as <br /> described above. Since arrangements have been made to pay the past due balance of <br /> $ , the Elk River Municipal Utilities will not disconnect electric services during <br /> the arrangement period unless the payment is under paid or late. Your current utility bill <br /> must also be kept current. Entering into this payment arrangement constitutes <br /> notice for disconnection of service for default of payment arrangement. If the proper <br /> payment is not paid or is late the utilities, at its discretion, may disconnect the electric <br /> service. If you are receiving assistance, you must still make regular payments and follow <br /> payment arrangement. <br /> Customer Signature: You can make payments on line at: <br /> www.elkriverutilities.com or 763-441-2020. <br /> Date: <br /> 120 <br />