Permanent Due Date

2. 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.

   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.

4. Date*
   Date

   Please insert today's date

5. Phone*

6. 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.

8. Account Holder's name

9. Service Address:

   Address, City, State, Zip

13. Permanent Due Date Information

15. Social Security /Disability Check is received on:*

16. Change Water/Wastewater Utility Bill Due Date to:*

20. 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

21. Date*
    Date

Leave This Blank:


22. Submit Submit and Print

* indicates a required field