AUTHORIZATION FOR AVERAGE MONTHLY PAYMENT (AMP)

Print this form and attach a VOIDED check and mail it to:

Acton Municipal Utility District

2001 Fall Creek Highway

Granbury, Texas 76049-7927

I attest that my utility bill is current and I will continue to keep it current throughout enrollment in the Average Monthly Payment (AMP).  I understand the amount billed is based on the most recent twelve-month average billing period; therefore, the monthly amount will vary slightly.

I understand that I must have twelve months of service at my current address before I qualify for average billing.  Failure to pay the amount billed by the due date will result in removal from the program and all balances are due in full at that time.

I understand that I can enroll for the Average Monthly Payment (AMP) during the enrollment window of  October, November and  December and I also understand that I can terminate the Average Monthly Billing (AMP) at any time by signing and dating the AMP termination form.  All balances are due in full when account is terminated.

AMP ENROLLMENT

Service Address: ________________________________________________________________________

City:  Granbury     State:  Texas       Zip: __________________ 

Day Time Phone Number:  ( __ __ __ ) __ __ __ - __ __ __ __       

Drivers License Number: ____________________________________ for the state of: _______________

Customer Signature: ____________________________________________________________________

Date signed:    Wednesday, December 26, 2007   

FOR OFFICE USE ONLY:                                                               

    ___    Must be a Residential Customer

    ___    Minimum 12 Months billing history

    ___    Account balance is current

    ___    No Disconnects allowed within the last 12 months

    ___    No NSF checks allowed within the last 12 months

    ___    No more than 2 late payments within the last 12 month