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2. I am applying for a Water and Sewer Bill Payment Assistance Plan from the City of Cotati. By applying for this assistance plan, I agree to the following terms and conditions:

   • Failure to comply with the terms of a payment plan may result in the issuance of a written disconnection notice. The disconnection notice will be in the form of a letter issued to the service location no less than seven businesses days in advance of discontinuance of water service.
   • The City reserves the right to file a lien against your property for any amount delinquent on your water bill outside of an agreed upon payment plan in good standing.
   • In the event of default on the payment plan, all applicable charges and penalties will be due immediately.
   • The amount due as part of the payment plan is in addition to the current water and sewer bill. It is the responsibility of the person signing the payment plan to pay the current portion of their bill. Failure to do so will be considered default of the payment plan.
   • Supporting Documents Required for Alternative Payment Arrangements include the following for residential customers:
     1. Certification by Primary Care Provider
     2. Support for Inability to Pay 
        1. Tenants/Non-Owner applicants - A signed copy of lease is required. The payment plan cannot extend past the timeframe of the lease.
   • Commercial Customer:
     1. Support for Inability to Pay 
     2. Application for Small Business Loan or Other Demonstrated Effort to Pursue Other Sources of Revenue
   • The account holder of record may not request further amortization of any subsequent unpaid charges while paying delinquent charges pursuant to an existing payment plan.
4. Account Holder Name*
5. Account Number*
6. Billing Period / Amount*
7. Owner/Tenant*
   -- Select One --OwnerTenant
9. Address
11. City
12. State
13. Zip Code
15. Phone Number*
16. Email Address*
18. Type of Extension Request*

    Note: See Discontinuation of Residential Water Service for Nonpayment Policy for details on each type.
    
    Extension of Payment of Bill:  To avoid late fees, the customer of record may request a short-term arrangement to pay the bill.  The customer of record must apply for an extension to pay the amount of the bill before a late fee is assessed. The extension may be granted through the 60th day after bill presentation.  
    
    Alternative Payment Arrangements:  
    Note: For tenant accounts, additional property owner consent will be required before approval of any payment arrangement. 
    
    In compliance with SB 998, the City will consider all circumstances surrounding the request and decide as to whether the Alternative Payment Arrangement is warranted. Reasons for inability to pay and need an alternative payment arrangement:
    
    1 - Certification by Primary Care Provider Certification by a Primary Care Provider who certifies that the discontinuation of water service will be life-threatening or pose a serious threat to the health and safety of any resident of the premise where water service is provided  
    
    2 - Financially Unable to Pay The account holder of record demonstrates they are financially unable to pay for water service within the normal billing cycle. The account holder of record or  member of the household, must be a current recipient of CalWORKs, CalFresh, general assistance, Medi-Cal, Supplemental Security Income/State Supplementary Payment Program, or California Special Supplementary Nutrition Program for Women, Infants and Children, or the account holder of record declares that the household’s annual income is less than two hundred (200) percent  of the federal poverty level. 

    
    

    1. Short Term Extension (Not to exceed 2 Weeks or 60 days from bill issuance)
    2. Alternative Payment Arrangements - Certification by Primary Care Provider
    3. Alternative Payment Arrangements - Financially Unable to Pay
20. Certification of Policy Understanding*

    By checking below I am certifying that I have read and understood the Policy for Discontinuation of Residential Water Service for Non-Payment as located on the City Website here: 

    https://www.cotaticity.org/DocumentCenter/View/589/Discontinuation-of-Residential-Water-Service-for-Nonpayment-Policy-PDF?bidId=

    1. Yes, I Agree That I Understand the Policy
22. Reason for Payment Extension*

    This reason does not guarantee approval, nor does it constitute a payment arrangement.

24. Applicant Name*
25. Date*
    Date
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field