Fillable WATER PAYMENT APPEAL FORM (City of Rollingwood)

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WATER PAYMENT APPEAL FORM (City of Rollingwood)

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By signing this form, you are promising to appear before the next Utility
Commission meeting.
WATER PAYMENT APPEAL FORM
Name on Account: _______________________________
Service Address: ________________________________
Account Number: ________________________________
Amount Due: ___________________________________
Telephone Number: _____-_____-_________
Email Address: _________________________________
Reason for Appeal to the Rollingwood Utility Commission: 1) Please identify the months
that you are contesting. 2) Please provide the reason for dispute. 3) Please provide 12
months of history. 4) Provide any other information to support appeal.
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Signature: _____________________________ Date: ____________
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WATER PAYMENT APPEAL FORM (City of Rollingwood)

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Completed 16 July 2020

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