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Step One

Payment Extension Request Form
Please fill out the following form to request a payment extension for your monthly utility bill.
Please note that submitting this form to the City of Melissa Utility Billing Department does not guarantee approval for a payment extension. After review, a staff member will respond via email.
Acknowledgement*
1. I agree.
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First Name*
Last Name*
Account #
Address*
Phone Number*
Numbers only, no dashes.
Email Address*
Payment Amount*
Past-due monthly balance
Payment Date*
Payment Date
Payment date must be no later than five business days after disconnect date.
I fully understand that if I do not pay as agreed, service can be terminated the next day and a $50.00 reconnection fee will be applied. All debt will be paid before service will be reconnected.
Acknowledgement*
1. I agree.
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Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date
Date

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