* indicates a required field

2. City of Blythe - Utility Billing Department
   235 N Broadway - Blythe, CA 92225
   (760) 922-6161 ext. 1233 or 1234
   

   Please complete all information:

4. First Name:*

5. Last Name:*

7. Service Address:*

9. Phone Number:*

10. Phone Type:

    -- Select One --Cell PhoneHome Phone

12. Account #*

13. Past Due Amount:*

14. Amount Due On:

    NOVEMBER 25, 2026

16. Email:*

    A signature is required to process your request.

    By entering your valid email address in the box above you are signing this form and confirming that you understand the following:

    • Failure to pay the total amount by 10:00am the day after the due date will result in disconnection of service.
    • A $44.00 reconnect fee will be charged, whether service has actually been disconnected.
    • Once disconnected, all amounts due will need to be collected to reestablish service.
    • Balances owed that are not received and credited to the account, by the 19^th day of the month, will be assessed a fee of 10%.
    • This is your final notice for the past due amount.
    • Extension forms can also be found in our office. Extensions are not given over the phone.
17. Date:*
    Date:

19. NO FURTHER EXTENSIONS WILL BE GIVEN.

21. Entered By: ____________________ Date Entered: __________
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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