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2. Date*
   Date
3. Account #

   08-067200-01

5. I,  Leon & Sonya Hunt,  agree to pay my total past due balance in the amount of  $_186.70_in ____1___ installments. This is in addition to my normal monthly bill amount. 

   First installment amount     $186.70        Date Due: 3-11-2022 before noon

    

7. I understand that I must pay with cash, Master Card, Visa, or Money Order only. 

   Checks are not accepted for payment arrangements.

   *** Once service has been disconnected for nonpayment, all delinquent fees plus the past due balance must be paid before service is reinstated. *** 

   NO EXCEPTIONS!

   
   

9. Electronic Signature Agreement*

   By checking the "I agree" box below, 

    I also understand and agree that my natural gas service will be discontinued without further notice if this agreement is not met. No dates or payment amounts will be changed once this arrangement has been made. Late fees will be applied to past due balances.

   
   

   1. I agree.
11. Electronic Signature*
13. Address*
14. Email*
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

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