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2. CITY OF BRISTOL, TENNESSEE
   FINANCE DEPARTMENT AGREEMENT FOR UTILITY BILL PAYMENT EXTENSION
4. CUSTOMER INFORMATION
6. UTILITY ACCOUNT NUMBER*
7. CUSTOMER NAME*
9. SERVICE ADDRESS*
10. CONTACT PHONE NUMBER*
12. IDENTIFICATION PROVIDED*
13. UPLOAD IDENTIFICATION
15. UTILITY BILL PAYMENT INFORMATION AND TERMS
17. AMOUNT IN ARREARS
18. DATE TO BE PAID OFF
20. I (We) hereby agree to pay the amount in arrears for this utility bill account to the City of Bristol, Tennessee in accordance with the following payment plan and terms:
22. The total amount due in arrears of $
23. within 5 business days or by (date)
25. The total amount due in arrears will be paid in two installments. $(dollar amount) is subject to immediate payment which represents 15% of the total amount due.
26. The remaining balance of $(dollar amount) is due within 10 business days
27. 10 business days which will be (date)
29. The total amount due in arrears will be paid in # installments
30. $ (dollar amount) is subject to immediate payment which represents 15% of the total amount due in arrears.
31. The remaining balance will be paid in equal monthly installments of $ (dollar amount) which are due by the pay gross after date stated on your utility bill until the account balance is paid in full.
33. In addition to this payment plan option, the current monthly charge for services must also be paid each month in a timely manner.
35. The total amount due in arrears of $ (dollar amount) will be transferred from a prior utility account to my current active account with the City.
36. Prior Account Number:
37. Current Account Number:
39. The transferred amount will be paid in (#) equal monthly installments
40. monthly installments of $ (dollar amount) which are due by the pay gross after date stated on your utility bill until the account balance is paid in full. In addition to this payment plan option, the current monthly charge for services must also be paid each month by the due date.
42. Failure to make payments in accordance with the terms indicated above will result in:
     Payment of the total amount due in full upon demand.
     Disconnection of existing utility services on the date that the agreement terms are broken.
     A service charge of $30.00 - $40.00 to restore utility services will be charged to your account.
     Additional payment agreements will not be allowed for a twelve month period.
    
    Two agreements in a twelve month period are the maximum allowed unless extenuating circumstances. Approval for an additional agreement must be granted by the Director of Finance, Accounting Manager, or Accounting Supervisor.
44. ACCEPTANCE OF AGREEMENT AND TERMS
46. 1. I (We) have read and accept the terms of this agreement as stated above.
47. Date
    Date
49. NAME(S)
50. NAME(S)
52. SIGNATURE
53. SIGNATURE
55. Please call a customer service representative at 423-989-5500 or email [email protected] with any questions regarding your agreement for a utility bill payment extension.
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