Glenn Heights, TX · Dallas County
Payment Arrangement Agreement Form
Utility customers use this agreement to request a payment arrangement for a past-due bill and acknowledge the consequences of not keeping the agreement.
What this form is
The form records an account holder’s request for a payment arrangement on a utility bill and the proposed payment amounts and number of months. It asks for the account number, account holder’s name and phone number, service address, payment details, and signatures and dates. The form warns that service may be disconnected if the agreement is broken.
Who needs it
A utility account holder seeking a payment arrangement for a past-due bill can complete this agreement.
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 agreement is signed without a notary; the account holder and city representative sign and date it.
How to submit this form
- 1
Download The Agreement
Download the Payment Arrangement Agreement Form PDF.
- 2
Complete Account Details
Enter the account number, account holder name, phone number, and service address.
- 3
Enter Payment Details
Fill in the requested payment amounts and number of months for the proposed arrangement.
- 4
Sign And Date
Sign and date the agreement. The form does not specify any attachments.
- 5
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
- What does the Payment Arrangement Agreement Form do?
- It records a utility account holder’s proposed payment arrangement for a bill, including payment amounts and the number of months.
- Who should complete this agreement?
- A utility account holder seeking a payment arrangement for a past-due bill can fill in the account and payment details and sign the form.
- Do I need a notary for the Payment Arrangement Agreement Form?
- No. This agreement is signed without a notary; the account holder and city representative sign and date it.
- How do I submit the Payment Arrangement Agreement Form?
- The form names the Utility Billing Department but does not give submission instructions. Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Payment Arrangement Agreement Form doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.