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   Complete the information below if your property is going to be unoccupied for 3 months or longer, and you want to cease utility bills.

5. Name (first and last):*
6. Account Number:*

   (8 digits - as shown on your utility bill.)

8. Service Address:*
10. Please confirm your email address:*
12. What date should we stop services?*
    What date should we stop services?
13. What is your anticipated return date?*
    What is your anticipated return date?
15. Would you like for the City of Monroe to disconnect your water?*
    -- Select One --YES - I would like for my water to be turned off on the date listed above.NO - I would like for my water to stay on while I am away.

    
    If you choose "Yes," the City will turn your water off sometime between 7:30am and 4:00pm on the stop service date that is listed above.
    If you choose "Yes," and choose a stop date on a weekend or holiday, the City will turn your water off the following business day.

17. IMPORTANT - Please acknowledge the terms below by entering a check mark:*

    1. I understand that the property must be unoccupied for a minimum of three (3) months in order to cease billing.
    2. I understand that I will be responsible for the monthly sewer flat charges, monthly street light charges, and monthly storm water charges that will accrue while billing is ceased. I agree to pay these charges, in addition to the trip charges above, upon my return.
19. IMPORTANT - Please acknowledge the terms below by entering a check mark:*

    1. I understand that the property must remain unoccupied for a minimum of three (3) months in order to cease billing.
    2. I understand that I must submit my request to restore water service at least three (3) business days in advance.
    3. I understand that I will be charged $35.00 for the trip to disconnect the water, and another charge of $35.00 for the trip to reconnect the water.
    4. I understand that I will be responsible for the monthly sewer flat charges, monthly street light charges, and monthly storm water charges that will accrue while billing is ceased. I agree to pay these charges, in addition to the trip charges above, upon my return.
    5. I understand that in certain circumstances, the City of Monroe may not be able to turn the water off at the street valve. I understand that it is my responsibility to turn water off at the main valve inside the home in order to prevent water leaks and water damage. The City will not be held responsible for compensatory damages due to water leakage in my home during my absence.
21. Emergency Contact Name:*
22. Emergency Contact Phone Number:*
24. 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.
26. Electronic Signature*
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field