Deferred Payment Request
By submitting this request, the customer agrees to pay the outstanding balance for water utility service under a deferred payment arrangement established by Riverside Special Utility District. The deferred amount will be divided into three equal payments, which will be due over the next three billing cycles in addition to the customer’s current monthly water service charges, rates, and fees. Any fees normally assessed by the District on unpaid balances will continue to apply to the declining balance until the account is paid in full.
Failure to comply with the terms of this agreement will result in the District initiating disconnection procedures, unless other satisfactory arrangements are made by the customer and approved by an authorized representative of the District. If service is disconnected due to non-payment, all applicable fees and the remaining balance under this agreement must be paid in full before service is reinstated.
Account Number
(Required)
Date of Request
(Required)
MM slash DD slash YYYY
Customer Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Customer Phone Number
(Required)
Customer Signature
(Required)
Use your finger or mouse to sign this agreement. Please note that electronic signatures are binding
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