City of Stayton
Administration • Finance
362 N. Third Avenue • Stayton, OR 97383
Phone: (503) 769-3425 • Fax (503) 769-1456
Number of Requests _____ out of _4_
UTILITY BILLING PAYMENT EXTENSION REQUEST AND AGREEMENT
Account No#: _____________ Full Balance owe $_______________
Account Name: _____________________ Account Address: __________________________
I agree to make full payment in the amount of $ ________________ Prior to 4:00 p.m.
on: _______________, for the account indicated above. Should I fail to make the payment by the time
agreed to, I understand and agree that the City of Stayton may discontinue water service to the address
indicated immediately and without further notice. I understand that a $50.00 processing fee will be
waived only if payment is made by the date and time indicated above. I understand that a payment
extension may only be made with the concurrence of the Finance Director and must be under unique
and unusual circumstances. I understand there is a limit of four occurrences per year which can be
claimed unless directed differently by the Stayton City Council.
I understand the Finance Director may increase to double the average monthly billing of the past year to
access the amount of the utility deposit if payments have been delinquent more than three times in the
past year. I acknowledge that I am the party responsible for this account, or I am the authorized agent
for the tenant or owner, and by my signature hold the City of Stayton Harmless from any and all liability
related to the collection of this account and the discontinuance of water and sewer for non-payment.
Date: _____________ Signed: _____________________________
Owner, Tenant, or Authorized Agent
Request for utility payment extension is: Approved; Denied.
Date: _____________ Signed: ____________________________
Finance Director, City of Stayton
