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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
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