E-Bill Authorization

2. E-Bill Authorization

4. First Name

5. Last Name

7. Address

9. City

10. State

11. Zip Code

13. E-mail address where e-bills will be directed:

15. I authorize the Borough of Seaside Heights to send the utility bills selected below to me via e-mail only. I understand that, if I select this option, I will no longer receive paper bills. I must notify the Borough of Seaside Heights in writing (not e-mail) if I choose to discontinue e-bill notification. I assume the responsibility for any and all consequences related to the failure to receive any e-bill.

17. Electric Account Number

    (If you do not want your electric bill sent via e-mail leave this blank)

19. Water/Sewer Account Number

    (If you do not want your water/sewer bill sent via e-mail leave this blank)

21. Name

    By typing your name you are acknowledging that this would be a signature.

22. Date

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field