City of Galena
211 W. 7
th
* Galena, Kansas 66739
Phone (620) 783-5265 * Fax (620) 783-5111
The Oldest Mining Town in Southeast Kansas
1877
AN EQUAL OPPORTUNITY EMPLOYER
Residential Water Service Shut-Off Request
I, _______________________________________________, the Owner or Renter do hereby
Name (Please Print)
request that the water service at the following vacant residence be terminated.
_____________________________________________________________________________________
Property Address
_____________________________________________________________________________________
Current Account Number Owner’s Telephone Number
_____________________________________________________________________________________
Date Service Should Be Terminated
_____________________________________________________________________________________
Forwarding Address for Final Bill
Essential Information – Please Read and initial all lines
____ I understand that all water valves on the customer’s side of the line should also be closed.
____ I understand that any prior charges must be paid and that penalty and interest will accrue on any
unpaid charges.
____ I understand that, after water service is terminated, there will be a final bill mailed the following
month to the above forwarding address.
____ I understand that my water deposit of $ ______ will be applied to the final bill.
The undersigned Owner or Renter of the property hereby releases The City of Galena, including its
offices, employees and agents from any and all liability related to the termination of water service, the
failure to terminate water service or the restoration of water service at the address shown above.
______________________________________________ _________________________
Owner/Renter Date
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