DO NOT SUBMIT PAYMENT WITH THIS FORM
City of Troy
Sanitation Dispute Form
Sanitation Disputes
City Hall
433 River Street, Suite 5001
Troy, NY 12180
518-279-7141
To dispute a sanitation invoice or violation you must fill out this form in its entirety and return it to the
Mayor’s Office in City Hall. All disputes must be submitted with the appropriate supporting evidence.
Failure to provide evidence or fill out this form completely will delay the process significantly and your
dispute may not be approved. The City of Troy will notify you of the result via email. If you do not
provide an email, all communication will be done through the U.S. Postal Service.
First name: __________________ Last name: _________________________ Date: _______________
Business name (if applicable):_________________________________________________
Primary phone number: ________________________________
Email address (preferred): __________________________________________________________
Property address(es) in question: _____________________________________________________
Bill/invoice number(s): ___________________________________________________________
Reason for dispute: ____________________________________________________________________
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Supporting documents included (check all that apply):
□ Police report
□ Photographic/video evidence (hardcopy)
□ Notarized statement from a neighbor or other party taking responsibility for the bill
□ Phone log
□ Other (please specify): ___________________________________________________________
REQUIRED:
By signing this form, I am attesting that the information provided on/with it is true to the best of my
knowledge.
Signature: __________________________________________ Date: ______________________
Administrative use only
□ Approved _____________________________________________ □ Denied __________________________________________
□ Processed □ In-person on ________________ Initial: _____________________ Date: _____________
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