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2. Note:
   Requests for payment extensions will be reviewed by our Collections Department. They will contact you to discuss your request.
4. Customer # - Account Number #
   Located on statement
5. Email Address*
7. Last Name*
8. First Name*
9. Phone Number*
11. Service Address*
13. City
    Lafayette
14. State
    Indiana
15. Zip Code*
17. Due Date
    Due Date
18. Extended Due Date Requested*
    Extended Due Date Requested
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field