REQ
UEST FOR UTILITY DEPOSIT REFUND
(A current Driver’s License and Social Security Number is required for all applicants)
The
City of Troy is committed to ensuring that your information is secure. In order to prevent unauthorized access or disclosure,
we have put in place suitable physical, electronic, and managerial procedures to safeguard and secure the information we collect.
A residential or mobile homeowner who completes this form shall be entitled to the return of his/her deposit
provided that timely and full payment was made for each and every utility bill in the consecutive 12-month period
immediately preceding the filing of this written request.
BELIEVING THAT I HAVE NOT BEEN DELINQUENT IN PAYMENT TO THE CITY AS STATED ABOVE, I REQUEST THAT MY
DEPOSIT BE RETURNED TO ME. BY CHECKING ONE OF THE BOXES BELOW, I ELECT TO HAVE MY REFUND:
o
MAILED IN THE FORM OF A CHECK
o
APPLIED TO MY ACCOUNT
(PLEASE PRINT)
Name on the Account:_____________________________________________________________________________
Account Number:_________________________________________________________________________________
Service Address:__________________________________________________________________________________
Contact Phone Number:____________________________________________________________________________
Signature: _________________________________________________ Date:________________________________
THIS SPACE RESERVED FOR OFFICE USE ONLY
Eligible?
o
Yes
o
No
Request received by:
o
Office
o
Mail
o
Fax
o
Email:_____________________________
Deposit to be returned: Electric: $______________________ Water: $_______________________
Refund processed by:_____________________________ Date:__________________________
301 Charles W. Meeks Avenue · PO Box 549 · Troy, Alabama 36081 | Phone: 334.566.0177 | Fax: 334.808.7404
Email: utilitybilling@troyal.gov | www.troyal.gov
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