2. About Social Services Donation
   In March 2012, the Manhattan City Commission passed Resolution 032712-A, authorizing the creation of a utility donation program for social services. As a result, city staff has developed a program to allow residents to make a recurring donation, on monthly utility bills, to help support social service agencies in Manhattan. If you would like to participate, please fill out the form below.
4. Authorization *

   I authorize the City of Manhattan’s Customer Service Department to add the amount listed below to each month’s city utility bill in support of local social service agencies in Manhattan, Kansas. I understand that this donation will continue each month as directed below. Further, I also understand that if my utility bill is delinquent for two (2) consecutive months, my monthly donation will cease immediately.

   1. Yes
   2. No
6. Name:*
8. Water Account Number (without dashes):*
10. What amount would you like to be added to your monthly utility bill for donation to Social Services in Manhattan?*
    (Must be in whole dollar amounts and a minimum donation of $1 please)
12. Please choose one of the following. *

    1. This monthly donation continues until I no longer require water service at the address noted below.
    2. This monthly donation shall end on the date listed below.
14. Address:
15. Date:
17. Contact Information*
    Please provide a phone number or email to be used in the event that there are any questions regarding your donation.
Leave This Blank:


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

    This field is not part of the form submission.

21. Submit Submit and Print

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