EmailMeForm
Project Help - Sharing Light, Water & Warmth
Yes, I wish to contribute to PROJECT HELP. Please state the amount (minimum of $1.00) that you wish to add to your Florence Utility Bill each month. You may discontinue this monthly authorization at any time by notifying Florence Utilities. Your contribution is tax deductible.
Name (As it appears on your bill)
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First
Last
Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Account Number
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Phone Number
*
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Monthly Contribution Amount
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Please type your name for authorization
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First
Last
Signature (Please use your mouse, stylus or finger to sign your name)
*
Clear
