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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 Help2Others Payment Assistance Program
12. 2-1-1 for Essential Community Services
14. Community Action Partnership of Riverside County
15. CVWD Utility Bill Assistance Information
19. Account Number - First 6 Digits*
20. Account Number - Second 6 Digits*
22. First Name*
23. Last Name*
25. Service Address Line 1*
27. Service Address Line 2
29. City*
30. Zip Code*
32. Mailing Address Line 1, if different from Service Address
34. Mailing Address Line 2, if different from Service Address
36. City
37. State or Province
38. Zip or Postal Code
40. Primary Telephone Number*
41. Primary Telephone Number Type*

    1. Cell Phone
    2. Home
    3. Work
43. Secondary Telephone Number
44. Secondary Telephone Number Type

    1. Cell Phone
    2. Home
    3. Work
46. Email Address*
48. Total amount owed:*
49. 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.

51. Is your account set up with autopay?*

    1. Yes
    2. No
52. 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.

54. Terms & Conditions
56. 1. I understand I must pay 20% of the full balance before this payment plan request will be approved
58. 1. If approved, CVWD will determine the payment plan duration regardless of my requested time period
60. 1. The water service account is in my name
62. 1. If approved, I agree to pay the installment payments IN ADDITION TO my monthly charges for the duration of the payment plan
64. 1. I understand that my first payment is due starting with my next bill
66. 1. I agree to keep my account current during the approved duration of the payment plan
68. 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
70. 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. *

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

    rev 03/2024

Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field