2. Date*
   Date
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Phone*
16. Email
18. Account ID Number
20. Deferred payment plan eligibility. The Administrator may enter into not more than one deferred payment plan per account per calendar year. The customer must submit an application demonstrating an extreme hardship to be eligible for a deferred payment plan. It is the intent of the City Council that extreme hardship will be recognized only in the most unusual circumstances. The Administrator has sole discretion to approve or deny an application, based on the following factors: (1) The extent to which the circumstance leading to the delinquency was caused by factors beyond the control of the customer; (2) The financial resources available to the customer; and (3) The likelihood that the customer will be able to perform under the deferred payment plan in a timely manner.
22. Deferred payment plans. If the Administrator approves a customer's application for a deferred payment plan, the customer will be required to execute a written agreement that: (1) Requires the customer to pay for all future services before the account becomes delinquent; (2) Provides up to, but no more than, six months to pay all delinquent amounts in equal or as nearly equal as practicable monthly installments; (3) Includes payment of a deferred payment fee at the time the plan is approved; (4) Provides that in the event of any default of the deferred payment plan, utility services and, for delinquent wastewater bills, water service provided by Martindale Water Supply Corporation, will be terminated/disconnected without further notice.
24. Section 1. Household Size / Description
26. Number of income-earning adults*
28. Number of Dependents (children, people with disabilities, other)*
30. Section 2. Monthly Household Income
32. Total Employment (salary, wages, tips)*
34. Total Public Assistance (SNAP, TANF, WIC, Social Security, other)
36. Total Child Support*
38. Total Other Income*
40. Section 3. Monthly Household Expenses
42. Housing (mortgage, rent, other)*
44. Utilities: Water*
46. Utilities: Electricity*
48. Utilities: Wastewater (sewer)*
50. Utilities: Solid Waste (trash, recycling)*
52. Total Communications (television, internet, phone, other)*
54. Total Insurance (automobile, home, renters, other)*
56. Total Liabilities (loans/debt payments)*
58. Unreimbursed Expenses: Total Education*
60. Unreimbursed Expenses: Total Child Care*
62. Unreimbursed Expenses: Total Employment/ Job-related*
64. Unreimbursed Expenses: Total Medical*
66. Section 4: Nature of Hardship
68. Please explain the nature of the hardship:*
70. Supporting Documentation
    (for example, completed unemployment application)
72. Section 5. Proposed Repayment Schedule
74. Past Due Amount*
76. Down Payment*
    (due at time of agreement signature)
78. Balance after Down Payment*
80. Select Repayment Terms Length*
    -- Select One --1 Month2 Months3 Months4 Months5 Months6 Months
82. Proposed Payment per Month
    (Divide the remaining balance after down payment by the number of months)
84. Service Fee*
86. Attestation
    By submitting this form, I certify that I have completed this application for a deferred payment plan fully and truthfully to the best of my knowledge. I understand that the City of Martindale may attempt to verify some or all of my statements to determine whether to establish a deferred payment plan agreement in accordance with City of Martindale Code of Ordinances Chapter 50, Sewer/Wastewater Provisions, and Chapter 51, Solid Waste and Recycling as applicable
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88. 1. Receive an email copy of this form.
89. Email address

    This field is not part of the form submission.

90. Submit

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