Payment Arrangement Plan | Kauai Island Utility Cooperative

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Payment Arrangement Plan (PAP) Request Form

Date of Request

Name on the Account

Account Number

Email Address

Home Phone Number

Cell Phone Number

Work Phone Number

Service Address

Address

City/Town

Mailing Address

Name (if different than account holder)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

I request to pay, on a monthly basis, my outstanding balance over the next (enter below) months.

Maximum of 3 months.

I agree to the terms and conditions.

Terms and Conditions

By signing below, I hereby agree to the following:

Monthly installment is in addition to the regular monthly bill on the account. All subsequent billings are payable when due.

The payment plan will commence the following month after the form is received and approved.

I understand that, should I default on making full payment of the amount due, Kaua’i Island Utility Cooperative (KIUC) shall limit or discontinue utility service and service will not be restored until the balance is paid in full and any associated fees are paid. I further understand that should I default on this agreement, KIUC will not allow another payment plan.

Applicant Signature

Sign above, the customer of record needs to make the request and sign.

Date of Signature

By clicking the "Submit" button, you consent to having all documents and disclosures provided or made available to you in electronic form, to the terms of this Agreement and to doing business with us electronically. You also consent and agree to the use of electronic records and electronic signatures in connection with transactions instead of written documents and handwritten signatures.

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