Payment Plans are considered on a case by case basis. Payment plan length is determined by examination of the applicant’s monthly household income, monthly household general living expenses, and individual circumstances determined at the time of the evaluation interview.
To apply for a payment plan, please complete the initial FINANCIAL EVALUATION APPLICATION form (Click “NEXT” at the bottom of the screen to access the application). Please complete the entire form to the best of your abilities. At the end of the form, carefully read each statement, check the corresponding box to agree, and sign to finalize your application.
(** Documentation indicating source of income could be: a copy of a recent paycheck stub, or social security payment, a copy of a form listing your AFDC, GA, or SSI benefits, etc.)
Applicant
Birth Date
Residence Address
Is the mailing address different from the residential address?
Mailing Address
Employer Address
Do you have a Spouse/Significant other?
Spouse/Significant other
Spouse/Significant other's Employer address
Dependent Children Living with You
Name of Friend/Relative
Address of Friend/Relative
Bank Account Type
Additional source of income
Paid How?
Documentation of income* is required at time of application. Please electronically attach copies of documentation indicating the source and amount of monthly income. * Documentation indicating source of income could be: a copy of a recent paycheck stub, or social security payment, a copy of a form listing your AFDC, GA, or SSI benefits, etc.)
Utility Total
I / We hereby authorize the City of Sacramento Revenue Division and its duly authorized representatives to contact any employer,bank, savings and loan, credit union, creditor, insurance company, attorney at law, or governmental agency regarding my / ourfinancial condition; and I / We further authorize such institution, individual, partnership, corporation, or agency so contacted torelease any or all information requested regarding my / our assets, liabilities, policies, litigations, financial transactions and accounts.
I / We authorize any financial institution, as defined in the California Right to Financial Privacy Act, to disclose to the City of Sacramento, Revenue Division and its duly authorized representatives, any or all information contained in my / our financial records. Said disclosable information shall include, but is not limited to, all accounts, assets, liabilities, and financial transactions maintained by said financial institution. I / We understand that I / We have the right to revoke this authorization at any time; and further, that in the absence of such a revocation, this authorization will automatically expire one (1) year from the date hereof.
You agree, that at any time should we need to contact you to collect money owed, we or our collection agency may use various dialing methods in order to reach you. Methods of contact at any number associated with your account including wireless telephone, which could result in charges to you, may include using pre‐recorded/artificial voice messages and/or use of an automatic dialing device as applicable. Our office an/or collection agency may also contact you by sending a text message or emails, using any e‐mail address you have provided. I/We have read this disclosure and agree that the Lender/Creditor/Collection Agency may contact me/us as described above.
Sign Here