Utility Payment Arrangement/Extension Request

Utility Payment Arrangement/Extension Request

I am applying for a Water & 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 (7) 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 & 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: o Residential Customer - (1) Certification by Primary Care Provider and (2) Support for Inability to Pay Tenants/Non-Owner applicants - A signed copy of lease is required. The payment plan cannot extend past the timeframe of the lease.

o Commercial Customer - (1) Support for Inability to Pay and (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.


Business Name (if applicable):   Address:

Phone Number:  Email Address:

Account Number:   Billing Period/Amount:

Type of Extension Request:  

*Note - See Discontinuation of Residential Water Service for Nonpayment Policy for details on each type.

Reason for payment extension:

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

Applicant Name:   Date:




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