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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. Number of Occupants:

11. Name / To

12. Phone

14. Mailing Address

16. City

17. State

18. Zip

20. Name / From

21. Phone

23. Forwarding Address

25. City

26. State

27. Zip

31. To

32. From

34. To

35. From

36. Office Use Only

    1. Vacant
    2. Snow Bird

38. Number of Units

39. Number of Occupants*

41. Sewer Code

42. Sewer Code

44. Storm Drain

    1. Resident

    1. Commercial

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

47. Comments

49. 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.

51. 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.

55. Signature*

56. E-mail Address:*

58. Date*

62. FM

63. Date

64. Taken By

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field