Form Center Module

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.

Utility Billing 15 Day Extension Application

Sign in to Save Progress

  2. CITY OF BLYTHE
    Utility Department
    235 N Broadway - Blythe, CA 92225
    (760) 922-6161 ext. 1233 or 1234

    PLEASE COMPLETE ALL INFORMATION:

  14. Amount Due On:

    JUNE 25, 2023

  16. A signature is required to process your request.

    By entering your valid email address in the box above you are signing this form and confirming that you understand the following:

    • Failure to pay the total amount by 10:00am the day after the due date will result in disconnection of service.
    • A $39.00 reconnect fee will be charged, whether service has actually been disconnected.
    • Once disconnected, all amounts due will need to be collected to reestablish service.
    • Balances owed that are not received and credited to the account, by the 19th day of the month, will be assessed a fee of 10%.
    • This is your final notice for the past due amount.
    • Extension forms can also be found in our office. Extensions are not given over the phone.
  19. NO FURTHER EXTENSIONS WILL BE GIVEN.
  21. Entered By: ____________________ Date Entered: __________
    22. Leave This Blank:

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