Today’s Date	[..]
Account Number	[..]
Requested Date of Reconnect	[..]

PLEASE CHECK ALL THAT APPLY

☐	Commercial	☐	Owner/Landlord
☐	Residential	☐	Rent/Lease

….

SERVICE ADDRESS:

By completing this form, you acknowledge that:

The water service to the relevant property will be reconnected on the date requested above.

For water service to be reconnected you must complete and submit the required document(s) and pay the required reconnect fee.

CUSTOMER INFORMATION

[…]

[…]

Customer Name:

Billing Address:

[…]
[…]
[…]
City	State	Zip Code

[…]

Phone Number:

Date
Printed Name
Signature

[.]	[…]

For Office Use Only
Date received:	[…]	Received by (initials):	[..]
Reconnect fee paid:	Yes	☐	No	☐	Amount Paid:	[..]
Date entered into billing system:	[…]	Entered by (initials):	[..]
Date sent to field:	[…]	Sent by (initials):	[..]
Date reconnected:	[…]	Reconnected by (initials):	[..]