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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. 

  7. Leave This Blank:

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