Valley Center, KS

Today's Date**

First Name*

Last Name*

Address1*

Address2

City*

State*

Zip*

Phone Number*

Driver's License #*

Account Number

Past Due Amount

Current Amount

Total

E-mail address

Reason for Request*

Text Field

PAST DUE AMOUNTS MUST BE PAID BEFORE THE 15TH OF THE MONTH. I AGREE TO PAY MY BILL AS FOLLOWS:

Past Due Amount*

Day I Agree to Pay*

I understand that by submitting this form, I have relinquished my rights for any further delinquent notification and that future notices will not relieve me of these arrangements. I understand that FAILURE TO PAY by the specified date on this form WILL CAUSE THE CITY TO DISCONTINUE MY WATER SERVICE at the specified address on this form. I understand that additional fees will be charged for any water service reconnection. This extension will not eliminate penalties being imposed. A City representative will contact you for additional confirmation.

Utility Payment Extension Form