2. Application for COVID-19 Emergency Flexible Payment Plan

4. COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE APPROVAL. APPLICATIONS WILL BE REVIEWED BY THE FINANCE DIRECTOR PRIOR TO APPROVAL.

6. Account/Application Information

7. I certify:*

   1. I am the Property Owner
9. Applicant Name: *
10. Account Number:*
11. Date:*
13. Street Address:*
15. Mailing Address: (if different than above.)
17. Phone Number:*
18. E-mail:*
20. I,*

21. have been financially impacted by the COVID-19 virus and request a flexible payment plan.

23. I request to pay my outstanding Covid-19 balance over the next

24. # of Months*

25. in equal installments (maximum 6 months for balances less than $500, and 12 months for all others). I understand that I will continue to be billed the regular, bi-monthly charges separate from the COVID-19 Emergency Flexible Payment Plan.  As the account holder, I understand that I am responsible for the amount due on my account.

27. Outstanding Amount $*
28. Divided by Number of Months*
29. = $ Payment Amount*

31. Payments may be made by cash, check, or by calling Finance at 360-629-2181 for credit card. 

    *Please Note COVID-19 on check memo line.

33. Terms and Conditions:

    • Payments are due by 20th of each month. No bill will be sent for this payment. 
    • Payments are in addition to the regularly accrued charges for the account.
    • Late penalties will not be assessed if all agreed upon payments are made on time.
    • Late penalties will be applied if payments are not made according to the agreement.
    • Tenant applications require both tenant and owner signatures with email addresses before submission for review.
    • I understand that, should I default on the payment as agreed, City of Stanwood may discontinue utility service and service will not be restored until the balance is paid in full plus any disconnect and reconnect fees. I further understand that should I default on this agreement; City of Stanwood will not allow another payment plan. All subsequent billings are payable when due.
    • If I need to revise this Payment Plan for any reason or if I am unable to make the agreed-upon payments set forth above, I agree to communicate this to City of Stanwood immediately in writing or by phone.

35. In consideration of the above and if the application is ultimately approved, the City of Stanwood will not pursue, and will essentially put on hold, any collection action against me. I understand that if I default or breach this agreement, City of Stanwood may pursue its right to collection action. I understand that I am in default if a payment is returned as insufficient funds (NSF) or is 45 days late. Customers must apply for a payment plan by December 31, 2021, to avoid late fees and disconnection of services.

37. 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.
39. First Name*
40. Middle Initial
41. Last Name*
43. For City Use Only:

    Approved By: __________________________________________	_____ Outstanding balance verified
    Rejected Reason:  ______________________________________	_____ Payment amount verified
    First payment Due Date: __________________________________

Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

* indicates a required field