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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.
Numbers only, no dashes.
Past-due monthly balance
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.
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.
This field is not part of the form submission.
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