subject_line
Keep Temple Beautiful
Utility Bill Donation Authorization Form
Utility Account Holder Name
*
Utility Account Number
🛈
Utility Service Address
*
Phone Number
*
Email Address
*
Monthly Donation Amount
*
$1.00
$5.00
$10.00
$20.00
Other
Other Donation Amount
Acknowledgement
*
By submitting this form, I authorize the City of Temple Utility Business Office to add my specified Keep Temple Beautiful donation amount to my monthly utility bill. Any donation that is added to a monthly bill will not be credited and will be due, in full, by the due date shown on each month's bill. In order to cancel my donation, I must contact the Utility Business Office at least 10 days prior to my monthly billing cycle, and make my cancellation request in writing. The request may be emailed to utilities@templetx.gov.
Name
*
Date Signed
*
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