Payment Arrangement Request Form

To submit a payment arrangement request, please provide the following information:
(For security purposes, please do not provide your electric account number.)

(*) Required Fields

*Type of Account:

*Island Region:

*Name on Account:

Business Name:

*Contact Name:

Contact Number:

*Email:

*Service Address:

*City:

*Zip Code:

*Requested Payment Date(s):

*Requested Payment Amount(s):

*Payment Method / Location:

*Have you ever been unemployed since March 2020?

*Has your ability to pay been negatively impacted by the COVID-19 pandemic (e.g., job loss, hour/wage reduction, business closure)?

Additional Information (Provide preferred payment arrangement option):

Security Check

Payment Arrangement Request Form

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