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2. 
3. Coachella Valley Water District
   Request to Enter into a Payment Plan
   
   
   
   
   
5. Please read and complete the information below to request a payment plan.
9. Other assistance programs
11. United Way of the Desert Help2Others Assistance Program
    Help2Others
12. Low Income Household Water Assistance Program (LIHWAP)
    LIHWAP
16. Account Number - First 6 Digits*
17. Account Number - Second 6 Digits*
19. First Name*
20. Last Name*
22. Service Address Line 1*
24. Service Address Line 2
26. City*
27. Zip Code*
29. Mailing Address Line 1, if different from Service Address
31. Mailing Address Line 2, if different from Service Address
33. City
34. State or Province
35. Zip or Postal Code
37. Primary Telephone Number*
38. Primary Telephone Number Type*

    1. Cell Phone
    2. Home
    3. Work
40. Secondary Telephone Number
41. Secondary Telephone Number Type

    1. Cell Phone
    2. Home
    3. Work
43. Email Address*
45. Total amount owed:*
46. Requested payment plan duration, in months*

    The requested number of months is not a guarantee that it will be approved.  CVWD will determine the payment plan duration based on your request, payment history, and total outstanding balance.

48. Is your account set up with autopay?*

    1. Yes
    2. No
49. Autopay

    To avoid having the full balance deducted with your next payment, autopay will be disabled for the duration of the payment plan.  Visit www.cvwd.org -> Login/Pay My Bill to re-establish the autopay schedule after your payment plan is fulfilled.

51. Terms & Conditions
53. 1. I understand I must pay 20% of the full balance before this payment plan request will be approved
55. 1. If approved, CVWD will determine the payment plan duration regardless of my requested time period
57. 1. The water service account is in my name
59. 1. If approved, I agree to pay the installment payments IN ADDITION TO my monthly charges for the duration of the payment plan
61. 1. I understand that my first payment is due starting with my next bill
63. 1. I agree to keep my account current during the approved duration of the payment plan
65. 1. If I fail to make payments as agreed, the payment plan becomes void, delinquency fees and late charges will be added to my account, and the TOTAL outstanding balance will become due IMMEDIATELY
67. 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. *

69. COACHELLA VALLEY WATER DISTRICT
    Post Office Box 1058
    Coachella, California 92236
    (760) 391-9600
    (760) 398-3190 - fax
    CustomerService@cvwd.org

    rev 1/2023

Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field