[Manatee County Government] Utilities Customer Assistance Commitment

Manatee County Utilities Customer Assistance Commitment

Customer Account Number

Form of Payment

Past Due Balance

Current Account Balance

Committed Amount

Phone Number

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

I am aware that by submitting this application, Manatee County Utilities staff will place a hold on the above account. I understand that if payment is not received within the 30-day extension, the hold on the customer’s account will be removed and will be in jeopardy of disconnection

Yes