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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City
10. State*
11. ZIP*
13. Phone Number*
14. Email*
15. Account Number *
17. Reason for requestnig your payment arrangement*

    1. Leak on property caused higher than average bill
    2. To avoid discontinuation of water service due to nonpayment (*see below for requirements)
    3. Loss of income due to COVID-19
19. *To avoid discontinuation of water service due to nonpayment, you must submit documentation showing that you meet the following requirements:
    1. Financial- you are declaring under penalty of perjury that household income is less than 200% of the federal poverty level ORsomeone in the household is a recipient of one of the following programs: CalWorks, CalFresh General Assistance, Medi-Cal, Supplemental Security Income / State Supplementary Payment Program, California Special Supplemental Nutrition Program for Women, Infants, and Children.
    
    2. Certification from a primary care provider that discontinuation of water service would be life threatening or pose a serious threat to the health and safety of a resident of the premises.
21. Required Documentation
    *Please upload the required documentation if you are requesting a payment arrangement to avoid discontinuation of water service due to nonpayment.
23. Payment Term

    The amount due will be based on the payment term. Please select your desired payment term:

    1. 3 months
    2. 6 months
    3. 9 months
    4. 12 months
25. Terms and Conditions
    If your service with the City of Poway is terminated prior to the final payment date, this arrangement becomes VOID, and all charges are due immediately. By submitting this form, you agree under penalty of perjury that the information you provided is true, whether stated or in writing. You, as the customer of record, are agreeing to a payment arrangement and all subsequent terms and conditions with the San Dieguito Water District, with respect to the delinquent charges and understand that service may be discontinued if payment is not made by the scheduled due date.
    
    Please note: You must continue to make manual, one-time payments towards current water bills as they are due.
27. Confirmation*

    1. I agree to the Terms and Conditions
28. Date*
    Date
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

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