Social Services Donation Form

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.

   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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