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2. 
3. Coachella Valley Water District
   Request to Enter into a 3 Month Payment Plan
   
   
   
   
   
5. Please read and complete the information below to request a payment plan.
   
   I understand and acknowledge that:*

   (Check all that apply)

   1. The water account is in my name.
   2. I have applied for the Help2Others program administered by United Way of the Desert (residential customers only).
7. Account Number - First 6 Digits*
8. Account Number - Second 6 Digits*
10. First Name*
11. Last Name*
13. Service Address Line 1*
15. Service Address Line 2
17. City*
18. Zip Code*
20. Mailing Address Line 1, if different from Service Address
22. Mailing Address Line 2, if different from Service Address
24. City
25. State or Province
26. Zip or Postal Code
28. Primary Telephone Number*
29. Primary Telephone Number Type*

    1. Cell Phone
    2. Home
    3. Work
31. Secondary Telephone Number
32. Secondary Telephone Number Type

    1. Cell Phone
    2. Home
    3. Work
34. Email Address*
36. Total amount owed:*
37. Acknowledgement*

    1. I understand that I must pay my monthly bill AND the payment plan amount for a period of 3 months from the start of this plan
39. Terms & Conditions

    If approved, I hereby agree to pay the installment payments IN ADDITION TO my monthly charges for a period of 3 months. I understand that my first payment is due starting with my next monthly bill.

    I agree to keep my account current during the time period requested above. If I fail to make payments as agreed upon, the payment plan will become void, delinquency fees and late charges will be added to my account, and the total outstanding balance will become due IMMEDIATELY.

41. By typing or signing my name, I certify that I understand the terms and conditions outlined above and that to the best of my knowledge the information I provided is true and correct. I understand this request must be approved by CVWD before it becomes valid and I will receive a written determination regarding this request. *

43. COACHELLA VALLEY WATER DISTRICT

    Post Office Box 1058

    Coachella, California 92236

    (760) 391-9600

    (760) 398-3190 - fax

    CustomerService@cvwd.org

    
    

    rev 5/2022

Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field