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2. First Name*
3. Last Name*
5. Street Number*
6. Street Name*
7. Street Type*
   -- Select One --AveBlvdCirCtDrRdSt
9. Date*
   Date
   Please provide the date you would like your service suspended.
10. Anticipated Return Date*
    Anticipated Return Date
    Please provide your anticipated return date.
12. Would you like the City of Monroe to disconnect your water?*
    -- Select One --YesNo
14. Emergency Contact Name*
15. Emergency Contact Phone Number*
17. I understand I must be gone for a minimum of three (3) months in order to temporarily cease billing. I understand I must contact the Utility Billing Office at least one (1) week in advance to have services suspended. If I opt to have the City of Monroe turn my water off/on at the main valve, I realize that I will be charged a trip charge of $35 each direction. In certain circumstances, the City of Monroe may not be able to turn water service off at the street valve. I understand it is my responsibility to turn water service off at the main valve inside the home in order to prevent water leaks and water damage. The City of Monroe shall not be responsible for compensatory damages due to water leakage in the home during my absence. I understand I am responsible for the monthly sewer flat charge and the trip charges and I will be billed for them upon my return.
19. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
21. Electronic Signature
25. Office Use Only
27. Account Number
29. Date
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field