City of Hot Springs Form Center

2. Full Name*
   (as shown on your utility bill)
4. Utility Account Number*
6. Please add the following amount to my monthly utility bill to benefit the H2O Hot Springs program:*
   -- Select One --$1$3$5$10$15$20$25or specify amount below

   Use dropdown menu to select your monthly contribution.
8. If specifying amount, enter here:
10. Number of monthly bills to include this donation:*
    -- Select One --1 month (1 time donation)2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months12 months

    Please select one
Leave This Blank:


12. 1. Receive an email copy of this form.
13. Email address

    This field is not part of the form submission.

14. Submit Submit and Print

* indicates a required field