Third Party Notification Form

2. Date*
   Date

   Please insert today's date

3. Phone:

4. Account Number *

   You can find the account number on the upper right hand corner of your monthly billing statement. Please provide the full account number including the dash.

6. Account Holder's name*

7. Service Address*

   Address, City, State, Zip

11. Third Party Information:

13. Third Party's Name:*

14. Phone

16. Mailing Address*

    Address, City, State, Zip

20. Acknowledgement and Signature *

    I authorize the Third Party to obtain a copy of my Water statement. I do understand that my account is confidential and this information can be given to the above noted Third Party. Ordinance No. 28: Identity Theft Prevention Program.

21. Date*
    Date

Leave This Blank:


23. Submit Submit and Print

* indicates a required field