Notice Of Consent To Turn Off Village Water Supply

Village of Fultonville

PO Box 337

Fultonville, NY 12072

Phone 518-853-3815

Fax 518-853-4813

 

Linda Petterson-Law, Mayor                                                                          Robyn Rose, Deputy Mayor

 

ACCOUNT #                      

Notice of Consent to TURN OFF Village Water Supply

THERE IS A $30.00 CHARGE FOR THIS SERVICE

 

This document serves as notice to the interested parties of the Village of Fultonville that I/we no longer wish to be served with water from the municipal water supply of the Village of Fultonville. Accordingly, a final meter reading will be taken, if applicable, and a final water/sewer bill be issued of which I/we agree to pay without penalty within 30 days of receipt of same. After 30 days a 10% penalty will be applied as prescribed by the rules and regulation governing water/sewer usage that are currently in effect. Upon failure to pay these charges within the current fiscal year they will be relevied to the Village property tax bill, _______(sbl#).

 

                                                                                                                                                           

                                                                                                                        Signature

 

Name:                                                                         Property Location:                                         

 

Billing Address:                                                          Phone #:                                                         

 

                                                                                    Date:                                                              

*** For Office Use Only: Work Order #                     ***

 

 

Date Notice Receive:                                                              Turned off for non-payment of rents: ___

 

Water Meter Reading:                                                            Date Read:                                                     

 

Disconnect fee N/A:                Paid:                Billed:             Bill Date:                  

                                                (Disconnect fee is not applicable to regular seasonal use only accounts)

This certifies that water/sewer service has been shut off, with a functioning water meter installed, as prescribed by the above notice on this date.

 

Date:                                                                                                                                                                                                                                                                                                    DPW Superintendent

 

Entered into BAS: Date                                                                                          By:                                                                                          

^{4/17/2018 2:13:42 PM}