Pilot Mountain, NC · Surry County
Request for Payment Plan
Utility customers use this form to request a payment plan for an account balance and provide contact, account, and payment schedule information.
What this form is
This form lets a utility customer request a payment plan and propose payment amounts and dates for an outstanding account balance. The form says requests must be made before service disconnection, and approval is not guaranteed. It asks for applicant and service details, account information, the reason for the request, and a payment schedule; applicants also acknowledge the plan’s terms and sign and date the form.
Who needs it
A utility customer seeking a payment arrangement for an account balance should complete this form before service disconnection.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; it asks the applicant to sign and date the request, with no notarized or sworn attachment mentioned.
How to submit this form
- 1
Download the Form
Download the Request for Payment Plan PDF.
- 2
Complete the Request
Enter applicant, service, and account details, explain the reason for the request, and provide a payment schedule.
- 3
Review and Sign
Review the listed requirements and terms, then sign and date the request.
- 4
Submit to the City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the Request for Payment Plan?
- No. The form asks the applicant to sign and date the request and does not mention a notarized or sworn attachment.
- How do I submit the Request for Payment Plan?
- Submit it to the city department named on the form; check the city website for current contact details.
- What information does the payment plan form ask for?
- It asks for applicant and service information, account balance and payment history details, the reason for the request, and a proposed payment schedule.
- Does submitting this form guarantee a payment plan?
- No. The form says requests are reviewed by supervisory personnel and that submitting a request does not guarantee approval.
Need something notarized?
This Request for Payment Plan doesn’t need a notary — but if you have another Pilot Mountain form that does, a commissioned online notary can help.