Owner Leave-On Request I will be responsible for electric, water, and / or sewer usage at the location(s) listed below. When a tenant moves out, these services will automatically be put into my name, provided that a normal request for disconnection has been requested. Note: If the tenant has been disconnected for non-payment, an attempt will be made by the Board of Public Works to contact the owner, provided they have given us a local phone number they can be contacted by. If, at this time, we are unable to contact the owner the services will remain off until the owner notifies the Board of Public Works. By signing this request, the property owner is responsible to contact the Board of Public Works if the property is sold, transferred, or vacated.Today's Date MM slash DD slash YYYY Customer Name*Customer Signature*Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number*Effective Date* MM slash DD slash YYYY Enter Service Location / Address Service Location / Address Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. CAPTCHA Δ
