2. Yes, I'd like to assist my neighbors in need of assistance with water service.
4. I want to give a monthly contribution to ensure delivery of water to my neighbors in need.

   Please indicate the amount to be added to your monthly water bill

   1. $1
   2. $2
   3. $5
   4. $10
   5. Other amount
6. If selecting "Other," please indicate the amount you would like to contribute through your monthly water bill.
8. I want to add a one-time contribution to my water bill in the amount of:
10. First Name*
11. Last Name*
13. Address 1*
15. Address 2
17. City
18. State
19. Zip
21. Water Account Number*
22. Phone Number (Home)
24. E-mail
26. How did you learn about Project SHARE? (check all that apply)

    1. WaterSource Newsletter
    2. Bill Insert in monthly water bill
    3. Water Business Office Representative
    4. The Salvation Army
    5. Website

    1. Radio
    2. Newspaper
    3. Friend/Word of Mouth
    4. Other*
28. *If answered "Other", please share how you heard of ACC's Project SHARE program.
30. I understand the amount indicated above will be added to my monthly water bill. The contribution is voluntary. *

    1. Yes
32. I understand that to discontinue monthly contributions, notice must be made to the Water Business Office 30 days prior to the next billing cycle.*

    1. Yes
34. The Salvation Army is a 501(c)(3). As a Salvation Army program, gifts to Project SHARE are tax-deductible.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field