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Utility Billing Change Form

2. City of Burlington

   Utility Billing Change of Service Form

   Utility Billing Change of Service Form

4. Property Address

5. Effective Date

7. Change of :*

   1. Ownership
   2. Business Ownership

   1. Billing Address

   1. Renter

   1. Copy to Renter

9. Name / To

10. Phone

12. Mailing Address

14. City

15. State

16. Zip

18. From

19. Phone

21. Forwarding Address

23. City

24. State

25. Zip

29. To

30. From

32. To

33. From

34. Office Use Only

    1. Vacant
    2. Snow Bird

36. Number of Units

37. Number of Occupants*

39. Sewer Code

40. Sewer Code

42. Storm Drain

    1. Resident

    1. Commercial

43. ESU's (Per 2,400 sq. ft.)

45. Comments

47. Billing periods are: Jan/Feb, Mar/Apr, May/June, July/Aug, Sep/Oct, Nov/Dec.<br> Sewer and Storm Drain billing is done bimonthly. Changes occurring within a billing period will be pro-rated by the day.

    Billing periods are: Jan/Feb, Mar/Apr, May/June, July/Aug, Sep/Oct, Nov/Dec.
    Sewer and Storm Drain billing is done bimonthly. Changes occurring within a billing period will be pro-rated by the day.

49. Senior Discount Rate

    Senior rates for Waste Management are available for those 62 and over. If you are eligible please contact City Hall Finance Dept at 360-755-2377.

53. Signature*

54. E-mail Address:*

56. Date*

60. FM

61. Date

62. Taken By

Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field