Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Agreement for Deferred Payment

  1. Agreement

    I hereby acknowledge that my water/trash account with the City of Chickasha has a delinquent balance. In order to receive this service, I hereby agree to make a payment on the following terms:

  2. Understanding*

    I understand if I fail to meet this agreement as I have signed, the water department at its own discretion may declare this agreement null and begin proceedings to terminate my water/trash service. It is further understood that any payment made under this agreement is in addition to my regularly scheduled payment and nothing herein relieves me of my obligation to pay in full any such bill as it comes due. In addition to my agreement I also understand if I do not follow strictly by the rules of this agreement I will no longer be allowed any such deferred payment plan.

  3. Your name typed below serves as your signature on this document.

  4. Leave This Blank:

  5. This field is not part of the form submission.