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2. RACS Utility Bill Donation Form

   Rosenberg residents can now make monetary donations to the Rosenberg Animal Control and Shelter (RACS) on their monthly water utility bill. The donated funds will be used to promote positive outcomes for shelter animals including caring for extenuating medical conditions, food/supplies and our TNR Program.

4. Donor Information

   Form must be completed by the utility account applicant or co-applicant.

6. Account Number*
7. Account Name*
9. Service Address*
11. Email Address
13. Phone Number*
14. Alternative Phone Number
18. Donation Description

    The option requested below by the account holder will automatically be added to your utility bill until the account holder chooses to discontinue the monthly donation by completing a request to remove the donation from the utility account.

20. RACS FIXED AMOUNT DONATION

    Choosing this option will add a set dollar amount (any amount) to your utility bill which will be automatically charged each month.

21. Monthly Dollar Amount
23. Please direct my contribution/donation to:
    -- Select One --Where NeededMedical ServicesTrap, Neuter & Release (TNR) ProgramFood/Supplies
25. OPT OUT – remove donation
29. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Applicant Electronic Signature*
32. Date*
    Date
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field