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Extended Leave Form

  1. Extended Leave - Billing Request
  2. Bill Forwarding Address:
  3. Services to be Discontinued:
  4. Sewer and Garbage:

    Check all that apply

  5. Authorization

    I authorize that this information is correct and will be billed accordingly. Dates will not be adjusted without proper notification beforehand to City personnel. 

  6. OFFICE USE ONLY
  7. Leave This Blank:

  8. This field is not part of the form submission.