Payment Agreement Form - Horsham Water & Sewer Authority

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HORSHAM WATER AND SEWER AUTHORITY
617 HORSHAM ROAD, HORSHAM, PA 19044
PHONE: 215.672.8011 FAX: 215.672.8065
PAYMENT PLAN AGREEMENT LETTER
Account #:__________________
Name: ______________________________________________________________
Phone #: _______________ (H) __________________(C) ________________(W)
Service Location: ____________________________________________________
Balance Owed: $________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
______________________________
_______/_______/_______
Signature
Date
If you have received a Shut Off Notice from the Authority you will not be eligible for payment arrangements.
Conditions to Authority payment agreements include but are not limited to the following, you must contact the
office and speak with a customer service representative in addition to submitting this request, as well as the past
due balance MUST be paid in full prior to your next billing period. Failure to comply with this agreement as
described above your property will be POSTED and service to the property will be TERMINATED.
***PLEASE NOTE, PAYMENT AGREEMENTS ARE SUBJECT TO THE APPROVAL OF HWSA***
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OFFICE USE ONLY:
HWSA clerk initials: ____________ Date Received: _______/_______/_______ Scanned: YES/ NO ____________
Approved YES / NO (circle)

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