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Round-Up Application

Water Account Number *

Name *

First

Last

Address *

Layout

City *

StateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip Code *

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Phone *

Email *

Please select an option *Round up to the next dollar amountRound up to the next dollar amount and add an additional $_____ more per month

Option 2 Additional Amount

Round-Up Agreement

I hereby authorize Community Water Company of Green Valley to Round-Up my Water Bill either to the next whole dollar amount or an additional dollar amount that I specify. I have the right to withdraw from Round-Up by notifying Community Water Company within five (5) business days of the billing date. If my account should ever be in arrears, I will be withdrawn from the plan. I understand that Community Water Company reserves the right to terminate this plan andor my participation therein. I understand that Community Water Company will forward the monies collected from the Round-Up Program to a local Charity for the purpose of helping other Community Water Company customers with the payment of their water bills. *

• I Agree

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