2. Name
3. Phone Number
5. Address
7. City
8. State
9. Zip Code
11. Customer Number
12. Account Number
14. Donation Type

    1. Round Up to Nearest Dollar
    2. Monthly Fixed Value
15. If Monthly Fixed Value, How Much?
17. I hereby agree that by clicking on the "Submit" button I am giving authorization to have my monthly Utility Bill "Rounded" up to the nearest dollar or have the fixed value donation added to my bill each month and that this money will go directly to the Change for Kids Fund for Santa Rosa Kids.
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

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