H2GO Brunswick Regional Water & Sewer

Round-Up Agreement

I hereby authorize Brunswick Regional Water & Sewer H2GO to Round Up my Water Bill either to the next whole dollar amount and/or an additional dollar amount that I specify.
I have the right to withdraw from Operation Round Up by notifying Brunswick Regional Water & Sewer H2GO by the next billing date (10th of each month).
If my account should ever be in arrears, I will be withdrawn from the plan.
I understand that Brunswick Regional Water & Sewer H2GO reserves the right to terminate this program and/or my participation therein.
I understand that Brunswick Regional Water & Sewer H2GO will forward 100% of monies collected from Operation Round Up to the designated Community Partners for the purpose of helping those in need.

Account Number:

Account Name(s):

First Name:

Middle Name/Initial:

Last Name:

First Name:

Middle Name:

Last Name:

Service Address:

City:

Email Address:

Phone #:

Type of Contribution:

(Y/N) Yes! Please round my bill up to the nearest dollar.

(Y/N) Please add the following amount to my "rounded up" bill each month as an additional contribution to Operation Round Up PLUS:

(Y/N) $1.00

(Y/N) $5.00

(Y/N) $10.00

Other Amount:

Authorized Customer Electronic Signature:

Signature Date:

Thank you for joining Operation Round Up!