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2. NOTE
   Utility Bill Extensions cannot be extended beyond the 20th of the following month in which the bill is due, in accordance with city code (Chapter 36, Article I). All extensions must be paid IN FULL by 5:00 P.M. on 20th of the following month or services will be disconnected and a $25.00 re-connection fee will be added to the account.
4. Name*
   Name as it appears on your account.
5. Service Address*
7. Phone Number*
8. Email Address*
10. I request an extension on the payment of my past due utility bill. I understand City of Clearwater records show a past due amount. The balance must be paid by the 20th of the following month the bill is due by 5:00 P.M or services will be disconnected.
    Amount due can be found through the Online Utility Payment.
12. Past Due Amount*
14. Notations
16. I understand that failure to pay the past due balance on the above reference date will result in the disconnection of water service and I will be responsible for a $25.00 re-connection fee.
18. A representative from City Hall will email you a confirmation the request was received and inform you if the request has been accepted.
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit Submit and Print

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