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2. First Name*
3. Last Name*
5. Service Address*
7. Phone Number*
9. Email Address*
11. Dispute Information
13. Billing Date*
    Billing Date
14. Amount in Dispute ($)*
16. Dispute Type (Select One):*
    -- Select One --Billing ErrorMeter Reading IssueService Connection/Disconnection IssueRate DiscrepancyLeak AdjustmentOther
18. Description of Dispute (Please provide details):*
20. Protest of Service Termination (If Applicable)
22. Date of Proposed Termination
    Date of Proposed Termination
23. Payment Provided to Prevent Termination

    (Payment must be equal to the average monthly usage at current rates.)

25. Note:

    An informal appeal must be made to the Director of Finance or their designee before submitting a request for a formal hearing. 

27. Request for Formal Hearing (If Applicable)

    If the informal appeal is unsuccessful, you may request a formal hearing. Submit this section within 48 hours of the informal decision.

29. Date of Informal Appeal
    Date of Informal Appeal
30. Formal Hearing Requested

    1. Yes
32. Certification

    I hereby certify that the information provided is accurate to the best of my knowledge and that I understand the dispute resolution process. I acknowledge that I must pay the undisputed portion of my bill and any payment required to prevent service termination.

34. Type Name:*
35. Date*
    Date
37. Driver License #*
38. Last 4 of SSN*
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field