Charitable Assistance Program Form

To participate, simply complete the form below. A Customer Service Representative will confirm your registration via a return e-mail.  Please allow two business days for processing.

Required fields are indicated with a * symbol. 

* Customer Name

Account Number: (if known)

* Service Address

* E-Mail Address

Security Check
letters are case-sensitive

Submit

By hitting "Submit" above, I authorize the Henry County Water Authority to round up my utility bill to benefit the Charitable Assistance Program. I understand that my bill will continue to be rounded up on a monthly basis unless I notify the Henry County Water Authority in writing, via regular mail or email, that I wish to discontinue the program.