2. This Deferred COVID-19 Payment Plan Arrangement (DCPPA) is an agreement by the account holder and/or current resident to reconcile a delinquent utility account.

   
   

   Effective September 30, 2021, the Washington State Water Disconnection & Late Fee Moratorium (Proclamation 20- 23) expired. This proclamation did not relieve customers from the obligation to pay for utility services nor will utility charges be discounted or waived. The City of Gig Harbor cannot gift public funds under current state law. For payment assistance beyond a DCPPA agreement please call 211.

   
   

   Once this form has been received, a Utility Billing Technician will follow up with your request. Filling out the form does not guarantee a payment plan arrangement. 

   
   

   **If this is a rental account, a copy of this Agreement will be sent to the property owner (or management company acting on the owners behalf). The City is not responsible for any fees or penalties that may be charged by the property owner (or management company acting on the owners behalf).

4. Account-Customer ID
6. Service Address
8. Bill Payer Name (First, Last)
9. Daytime Phone Number
10. Email Address
12. Owner Name (First, Last)
13. Daytime Phone Number
14. Email Address
16. Please select the payment option you are requesting:
18. Past Due Amount (check one):

    1. $500 or less - Maximum Payment Terms of 4 Months or 2 Billing Periods
    2. $501 to $1,000 - Maximum Payment Terms of 8 Months or 4 Billing Periods
    3. $1,001 to $ 1,500 - Maximum Payment Terms of 12 Months or 6 Billing Periods
    4. $1,501 to $2,000 - Maximum Payment Terms of 16 Months or 8 Billing Periods
    5. Greater than $2,000 - Maximum Payment Terms of 20 Months or 10 Billing Periods
20. Minimum Payment Request $
21. Frequency (check one):

    1. Weekly
    2. Bi-Weekly
    3. Monthly

25. I have been unable to pay the past due balance on my account because of the financial hardship resulting from the COVID-19 Pandemic. Therefore, I am formally requesting that I be considered for inclusion in the City of Gig Harbor’s Deferred COVID-19 Payment Plan Arrangement.

    
    

    I am aware that I may be required to provide financial information and other documentation to establish eligibility.  I also agree that the City of Gig Harbor may contact me at the phone number, email or address provided.

    
    

    I hereby accept the City of Gig Harbor’s offered extended payment plan, and understand and agree to the following by signing and dating this arrangement form below:

    
    

    • There is an interest rate of 8% per annum amount past due added to my past due balance.
    • Installment payments must be made by the last business day within the week, bi-weekly or monthly payment frequency selected on the reverse side of this form by the applicant.
    • Applicant is responsible for tracking these payments, no separate statement or reminders will be sent for this payment plan arrangement.
    • A residential customer whose financial condition changes during the term of this payment arrangement, or a customer who defaults on a payment and who seeks to reestablish the payment plan, may do so one time under the same terms described in this signed agreement.
    • DCPPA payments under this agreement are in addition to future regularly accrued bi-monthly utility charges for the account. All subsequent billings are payable when due.
    • Current billing statements must be paid by the due date.
    • Accounts in violation of their DCPPA are subject to the normal disconnection policy.
    • There are no reminder calls or notices sent for payments pertaining to this agreement. Failure to pay on the agreed frequency dates will result in immediate loss of service, without any further notice. Payment in full, plus all penalty charges will be required to restore service and may take up to three days.

27. I certify, under penalty of perjury, that all statements on this form are true and accurate to the best of my knowledge. I understand that this arrangement may be revoked if I fail to notify the City of changes to my financial situation or living arrangements, if I have provided false information or fail to meet payment arrangement terms. This could result in associated fees being assessed, termination of utility services and/or further collection actions which may include a lien placed on the property.

29. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Electronic Signature
32. Date
    Date
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field