CITY

GOVERNMENT

E-Billing Sign-Up Form

Please complete the form below to enroll in E-Billing for the city of Lavonia. If you have any questions about this service, please contact our office.

Customer Name *

First

Last

Spouse's Name (if an account)

Account Number *

Email Address *

Home Phone *

Cell Phone *

Emergency Contact Name *

Emergency Contact Phone *

City of Lavonia now offers an E-Bill Option. How would you like to receive your bill? *

Paper
Email

Any change in the E-Bill status will only take effect the next time water bills are prepared. Customers are solely responsible for updating their E-Bill information and E-Bills not received are the sole responsibility of the customer. YOU MAY ONLY SELECT ONE OPTION. If you select E-Bill, you will not receive a paper bill by mail.

Customer Signature *

Please type your name as it appears on your account. By entering your name above, you attest to be the account holder named above and consent to the terms and conditions of e-billing.

Signature Date *

Please enter today's date using the mm/dd/yyyy format.