PaymentOptions

Extended Payment Due Date Plan Enrolment Form

Account Number:
First Name:
Last Name:
Address:
City, State, Zip:
Home Phone:
Work Phone: (optional)
Social Security Number:
Email Address: (optional)
My main sources of household income come from:
	Disability Payments
	Social Security Benefits
	Aid to Families with Dependent Children
	Other Government Sponsored Low-Income Assistance Programs

I normally receive my check on the (date) of the month.
Pepco can verify the above information with:
Agency Name:
Address:
City, State, Zip:
Phone Number:
Agreement I understand that all amounts due, except my current months charges, must be paid in full before my application will be accepted. I am enclosing $ in payment of all outstanding arrears on my account.
I agree with the above (box must be checked in order to apply for this plan).