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2. Account Holder Name
4. *Account Number

   *Your account number is located in the upper left-hand corner of your bill. 

6. Address

   Please include your entire address, including street number (unit or apartment number if applicable) and name, City, State, and Zip Code. 

8. Home Phone
9. Cell Phone
10. Email
12. Payment Amount Agreement Statement

    I am not able to adhere to the payment plan set forth by the City of Escondido, as it will cause financial hardship. I am able to pay an additional $_______ per bill (the minimum payment is $5 per unit/per month).  

    I understand that a City of Escondido employee will contact me within 10 business days to go over the acceptance of this payment plan.  

14. Additional Payment Amount

    Please type the dollar amount per bill that you agree to be billed. 

    The minimum payment amount is $5 per unit/per month.

16. Signature & Date

    Please "sign" by typing your entire name and the date.

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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field