Aqua Aid Donation Form


Aqua Aid is an assistance program that enables customers in need to receive uninterrupted service. The program is funded by donations from Aqua customers. Please fill out the form below to donate.

Field is required
Field is required
Field is required
Field is required
Field is required
Field is required. Zip code must contain only numbers. If specifying the ZIP+4 code, separate with a dash or space.
Enter a valid zip code.
Field is required, and needs to be a valid email address.
Field is required. Account number must contain exactly 16 digits.
Enter your 16-digit account number using numbers only.
Field is required
Choose donation amount from the dropdown: $1, $3, $5 or other.
Enter a valid dollar amount for your donation amount.
Please enter the amount of a one-time donation, or a custom monthly donation.
Field is required