Name(Required) First Last Account Number(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email(Required) Agreement and Consent(Required)By submitting this form you are agreeing to pay 10% of your entire balance or $50, whichever is more and paying the remaining amount of your past due, after this payment, two weeks from today. Before this arrangement can be valid you must either log on to your smarthub account or call in to the (844) 344-4369 phone number and pay 10% of your entire balance (not just the past due balance) or $50, whichever is higher. Payments must be made with guaranteed funds (no checks). Once this payment is made, an arrangement will be made and the remaining balance of your past due will be due on or before 2 weeks from today’s date. You will receive a copy of your arrangement via email that will have your exact due date and amount owed. If the terms of this agreement are not met, this agreement will be cancelled and your electric service will be scheduled for disconnection without further notice and another agreement cannot be established for another 12 months. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Member Electronic Signature (Full Name)(Required) PhoneThis field is for validation purposes and should be left unchanged.