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Delayed Payment Plan Application

Simply complete and print this form. You may mail the signed completed form to Gibson EMC,   P.O. Box 47, Trenton, TN 38382 or deliver it to any one of our member service centers.

I hereby certify that I meet the Delayed Payment Plan eligibility requirements. I understand that bills should be paid in full by the due date, and that partial payments must have prior approval of Gibson EMC. I further understand that if my bill is unpaid after the due date, a late change of 5% is added; that my service may be terminated if my bill is unpaid three days after due date; and that if service is terminated twice during a 12-month period, I'll be removed from the Delayed Payment Plan.
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