RESIDENTIAL CUSTOMER DEFERRED PAYMENT AGREEMENT

Customer's Name:_____________________________________Phone: _________________

Service Address:_____________________________________________________________

Account Number: ____________________________________________________________

At this address, how many adults?____ children?____ disabled/elderly?____

ABOUT THIS AGREEMENT

This is an agreement by_______________________ (customer name) to make periodic installment payments to the Village of Bergen Municipal Electric Department of an overdue balance owed for electric utility service. It is also an agreement by the Village that it will provide electric service to the address listed above as long as you make these payments, and full payment of each current bill, on time. This payment agreement includes amounts owed for electricity only.

PAYMENT AGREEMENT RULES

This agreement requires regular periodic payments which have been based on your demonstrated ability to pay. If you believe you are unable to pay on these terms, you should not sign this agreement. Instead, call us at (585) 494-1513, or come to our office at 11 Buffalo Street, Bergen, New York 14416.
Deferred payments agreements may be agreed upon between the customer and the Village ( see "Deferred Payment Agreement Sheet "). If you can show financial need, alternative terms will be arranged. Depending on your circumstances, a down payment may not be required and installments may be as low as $10.00 per month. You may be required to complete a form showing assets, income and expenses and provide substantiation of such information.
This agreement can be changed if your ability to pay changes significantly for reasons you cannot control. If a change is needed, please call (585) 494-1513, or come to our office.
If you are a recipient of public assistance or supplement security income, you may be eligible for help in paying your utility bills. If so, you may wish to call or visit your local Social Services office.

HOW MUCH IS TO BE PAID

Total amount you owe the Village for unpaid electric service as of

________________________________________________is $ __________________

HOW PAYMENT IS TO BE MADE

You are to pay the amount owed in the following way:

A down payment of $ ________________ is to be received by ____________.

Installments of $ _______________ are to be received by the ______________

each ___________________ from ____________ to ____________.

The balance of $ ____________________ is to be received by _______________.

Any bill we send you after _____________________ is due when you receive it.

LATE PAYMENT CHARGES

This agreement is subject to late payment charges at a monthly rate of 1.5 % which is the equivalent of an annual rate of 18%. Late payment charges will be calculated on the amount of the balance after the late payment date shown on each monthly bill. The total late payment charges for the duration of this agreement are calculated to be $ _______________. This amount is based upon timely payments. The actual late payment charge you pay will be either lower or higher than the amount indicated if you make payments either early or late.

WHAT HAPPENS IF PAYMENTS ARE NOT MADE

If we do not receive these installment payments or your regular bill payments on time, we will send you a notice requiring you to pay the total amount owed on your account, and you will then have only 15 days to pay in full before your electric service is turned off.

A dishonored check will result in immediate termination of service without further notice, a $20.00 bounced check fee and a $30.00 reconnection fee.

ASSISTANCE

IF YOU ARE UNABLE TO PAY THE TERMS OF THIS AGREEMENT, OR NEED HELP UNDERSTANDING THIS AGREEMENT, CALL US AT (585) 494-1513, 8:00 A.M. TO 4:30 P.M., MONDAY THROUGH FRIDAY.

IF FURTHER HELP IS NEEDED, YOU MAY CALL THE NEW YORK PUBLIC SERVICE COMMISSION AT (800) 342-3377, 8:30 A.M. TO 4:30 P.M., MONDAY THROUGH FRIDAY.

ACCEPTANCE OF AGREEMENT

I have read, understand, and accept this agreement.

Customer's Signature:________________________________________Date______________

Village Signature: ___________________________________________Date _____________

One copy of this agreement, signed by the customer, with the down payment, must be received by the Village in order to avoid having your service turned off.

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