Riverdale City
Authorization Agreement for Utility Billing Equal Pay
(To sign up for Equal Pay you must also sign up for Direct Pay)

Your Personal Information

Name: _________________________

Address: ______________________

Telephone Number:
Account Number: __________________(As appears on your utility bill.)

Set-up New Agreement: _____

Cancel Agreement: _____

Your Authorization

I hereby authorize Riverdale City to set up equal pay amounts for my utility bill. I understand that this amount will be based on the previous twelve months of service.  I understand that Riverdale City reserve the right to terminate this payment plan and/or my participation therein.  I also understand that at any time I may elect to discontinue my enrollment in this plan by providing written notice to Riverdale City.

  ____________________________         ____________________

             Signature                                   Date

Mail or return this form to:

Riverdale City

4600 S. Weber River Drive

Riverdale, Utah 84405