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2. Date*
   Date
4. First and Last Name*
6. Service Address*
8. Account Number*
10. Phone Number*
12. Email Address*
14. Original Due Date of Bill*
16. Please enter the amount you are able to pay today if this payment arrangement application is approved?*
18. Date remainder will be paid:*
20. Questions or Comments:
22. Application Verification If payment is not received in full by the date above or 15 days from the service terminated date noted on the bill, I understand my water service will be shut off and a $50 fee will be added to my utility bill.I also understand I'm limited to 2 payment arrangements per 12 month period, per SMC 15.05.060. Please enter full name below.*
24. Once you submit the utility payment arrangement application a staff member will contact you via email to confirm or deny your request. Please allow at least one business day for a response. If you have a question you may email utilitybilling@snohomishwa.gov.
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26. 1. Receive an email copy of this form.
27. Email address

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28. Submit

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