Monthly Budget Payment Agreement – Fillable

Budget Payment Agreement APPLICANT INFORMATION Applicant Name: Phone Number: Email Address: Mailing Address: ACCOUNT DATA Utility Service Address: Utility Account Number: Payment Date: ☐ 5th ☐ 10th ☐ 15th ☐ 20th Payment Amount: Bank Name: Bank Routing Number: Bank Account Number: Account Type: ☐ Checking ☐ Savings APPLICANT ACKNOWLEDGEMENT I, the undersigned, authorize the Village of Marathon City debit the above identified account via ACH as defined above. I further agree that any and all fees associated with insufficient funds, r eturns or transactional administration costs may be collected by the Village of Marathon City. I further acknowledge that if I, as the Customer, fails to make payments as agreed, the customer shall be notified with the next billing that if proper payment is not received subsequent to this notification, the net regular billing may effectuate the removal of the customer from the budget pan and reflect the appropriate amount due. If the customer fails to make additional payments the entire outstanding utility balance on my account will become due and payable without further notice. If the customer cannot pay their balance in full they may enter into a Deferred Payment Plan with the water utility. Failure to make any payments shall also constitute cause for disconnection of service after due notice in accordance with the applicable rules on disconnection of the Public Service Commission of Wisconsin then in force. In the event service is disconnected, it shall be reconnected only upon payment of all past due charges and reconnection fees. Signature: Date: DEFERRED PAYMENT AGREEMENT REVIEW (Office Use Only) ☐ Application Completed ☐ Customer Signature Obtained Marathon City – Director of Public Works 311 Walnut Street PO Box 487 Marathon City, WI 54448 (715) 443-2221 Submission Date: Accepted By: Approval Date: Approved By: