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2. Extended Leave - Billing Request
4. Leave Date:*
   Leave Date:
5. Return Date:*
   Return Date:
7. Name*
9. Street Address*
11. City, State, Zip Code*
13. Phone Number*
14. Email*
18. Bill Forwarding Address:
20. Address
22. City
23. State
24. Zip Code
28. Services to be Discontinued:
30. Sewer and Garbage:

    Check all that apply

    1. Sewer - Minimum fee will be charged each month (Water turned off within the home by Homeowner)
    2. Sewer - Minimum fee will NOT be charged each month (Water turned off by Iowa American Water /or/ Property has a well)
    3. Garbage - Minimum fee will NOT be charged
32. 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. 

34. Signature:
38. OFFICE USE ONLY
40. Meter Read:
41. Date Read:
42. Reactivated Date:
44. Notes:
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field