Form Center

2. I am applying for a Water and Sewer Bill Payment Assistance Plan from the City of Cotati. By applying for this assistance plan, I agree to the following terms and conditions:

   • Failure to comply with the terms of a payment plan may result in the issuance of a written disconnection notice. The disconnection notice will be in the form of a letter issued to the service location no less than seven businesses days in advance of discontinuance of water service.
   • The City reserves the right to file a lien against your property for any amount delinquent on your water bill outside of an agreed upon payment plan in good standing.
   • In the event of default on the payment plan, all applicable charges and penalties will be due immediately.
   • The amount due as part of the payment plan is in addition to the current water and sewer bill. It is the responsibility of the person signing the payment plan to pay the current portion of their bill. Failure to do so will be considered default of the payment plan.
   • Supporting Documents Required for Alternative Payment Arrangements include the following for residential customers:
     1. Certification by Primary Care Provider
     2. Support for Inability to Pay 
        1. Tenants/Non-Owner applicants - A signed copy of lease is required. The payment plan cannot extend past the timeframe of the lease.
   • Commercial Customer:
     1. Support for Inability to Pay 
     2. Application for Small Business Loan or Other Demonstrated Effort to Pursue Other Sources of Revenue
   • The account holder of record may not request further amortization of any subsequent unpaid charges while paying delinquent charges pursuant to an existing payment plan.
4. Name*
5. Account Number*
6. Billing Period / Amount*
8. Address
10. City
11. State
12. Zip Code
14. Phone Number
15. Email Address*
17. Type of Extension Request

    1. Short Term Extension
    2. Alternative Payment Arrangements

    Note: See Discontinuation of Residential Water Service for Nonpayment Policy for details on each type

    
    

19. Certification of Policy Understanding*

    By checking below I am certifying that I have read and understood the Policy for Discontinuation of Residential Water Service for Non-Payment as located on the City Website here: 

    https://www.cotaticity.org/DocumentCenter/View/589/Discontinuation-of-Residential-Water-Service-for-Nonpayment-Policy-PDF?bidId=

    1. Yes, I Agree That I Understand the Policy
21. Reason for Payment Extension

    This reason does not guarantee approval, nor does it constitute a payment arrangement.

23. Applicant Name
24. Date
    Date
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field