2. Customer Name
4. Account Number
6. Address
8. City
9. State
10. Zip Code
12. Phone
14. Email
16. 1. Please change my account to the Budget Billing Program.

    I understand that I will not be able to change from Budget Billing for 12 months and that I must keep my account current to continue on Budget Billing.
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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