Section 1 of 1 in this document
Manatee County Utilities Customer Assistance Commitment
Customer Name
First Name
*
Last Name
*
Customer Account Number
*
Form of Payment
*
Full Address
Street Address
City
State
Zip
Past Due Balance
*
Current Account Balance
*
Committed Amount
*
Phone Number
Sign Here
Sign Here
First Name
Last Name
Email
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
disregard this