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E-billing

2. Date*
   Date

3. Account #

5. First Name

6. Last Name

8. Address

10. City

11. State

12. Zip Code

14. Email Address

15. Phone Number

    123-123-1234

17. Disclaimer*

    1. Accepted

    The City of Elkhart utility bill is the 10th of each month. Please remember the bill is due each month regardless of whether an email was received.

19. To stop E-billing

    If at any point you wish to stop receiving paperless bills contact the utility department at utilitybill@elkhart.com or 620-697-2554

    If at any point you wish to stop receiving paperless bills contact the utility department at utilitybill@elkhart.com or 620-697-2554

21. 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.
23. Electronic Signature

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field