Information Request Form

Stormwater Delinquency Assistance Request

Use this form to request delinquency assistance for your stormwater account.
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Stormwater Account - Customer Number
Account Number - Customer Number (From Utility Bill)
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am requesting:

A one-time waiver of the penalty fees assessed to my account.A payment agreement for my outstanding balance.
Reason for Request:*
Provide the reason for your request for assistance.
Terms and Conditions
By signing and submitting this form, I acknowledge and agree to the following:
- I am requesting one-time relief for my outstanding stormwater utility balance.
- I confirm that I am the property owner for the account listed on this request.
- I understand that approval of this request is subject to City review and eligibility requirements.
- If approved, I agree to comply with all terms and conditions associated with the relief option granted.
Signature*

Clear
Please verify that you are human*
Should be Empty:

Stormwater Delinquency Assistance Request