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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