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Extension Request Form

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6. City of Dothan - CD102-34(f)(3) No extension will be granted to a customer who has been extended three times in the preceding 12 months.

   City of Dothan - CD102-34(f)(3) No extension will be granted to a customer who has been extended three times in the preceding 12 months.

8. I understand that by entering into this agreement, the full delinquent balance must be paid by the extension date. The amount extended in this agreement cannot be granted any additional extension.

   I understand that by entering into this agreement, the full delinquent balance must be paid by the extension date. The amount extended in this agreement cannot be granted any additional extension.

10. I understand that if the account is disconnected for failure to fulfill this agreement, additional fees will apply.

    I understand that if the account is disconnected for failure to fulfill this agreement, additional fees will apply.

12. Customer Acknowledgement of Understanding*

    1. I understand the extension information listed above

14. Customer Name*

15. Customer Address*

17. Driver's License Number*

18. Telephone Number*

20. Reply Email*

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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

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