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Permanent Due Date
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Instructions
This application is for customers on a fixed income, which means that they receive one (1) check per month at a scheduled time. You do not qualify if you are employed and receive regular paychecks. You will be subject to late fees, penalty fees, or disconnection of service for nonpayment.
Date
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Date
Please insert today's date
Phone
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Account Number
*
You can find the account number on the upper right hand corner of your monthly billing statement. Please provide the full account number including the dash.
Account Holder's name
Service Address:
Address, City, State, Zip
Permanent Due Date Information
Social Security /Disability Check is received on:
*
Change Water/Wastewater Utility Bill Due Date to:
*
Acknowledgement and Signature
*
I understand that if I do not pay by the permanent due date listed above, that my account is subject to: late fees, penalty fees, and that service may be disconnected in accordance to the City of Rio Rancho Ordinances. I also understand that I will need to provide proof that I am on a fixed income
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Date
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