City of South Bend Sewer Insurance Program Policy Revision

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ExhibitB Billing Address: SEWER REPAIR REIMBURSEMENT AGREEMENT City of South Bend, Indiana Date: Borrower's SSN: I, _ , (Borrower) of _ South Bend, Indiana promise to pay to the order of the Sewer Repair Fund, South Bend Water Works, 125 West Colfax Avenue, P.O. Box 1714, South Bend, Indiana 46634, the sum of $500 as follows: One hundred dollars ($100) at the time of the execution of this note, followed by 11 monthly payments of $33.34, and one final payment of $33.26 (total 12), all added to my South Bend water bill at the address listed above which I agree to pay. I understand that there will be no interest charged on the amount due pursuant to this note as long as my payments are current, but that during any period of delinquency, I will be charged interest at the rate of eight percent per annum. I hereby waive presentment for payment, protest, notice of protest, and nonpayment of this note, and agree that upon default in payment of this note, or any part when due, the whole amount remaining unpaid shall, without notice or nonpayment or demand of payment, immediately become due and payable, with attorney's fees and without relief whatsoever from valuation of appraisement laws. I understand that if the total cost of repair is less than $500, that Water Works shall amend my payment schedule to match the actual cost of the repairs. Contact Person for Borrower (excluding spouse): BORROWER: Name & relationship to Borrower (Pleaseprint) (Signature) Telephone No: Telephone No: State of Indiana ) ) SS: St. Joseph County ) Subscribed and sworn to before me, a Notary Public in and for said County and State this day of ,20 . Notary Public Commission Expiration Date 10