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 Transfer Request
I, _______________________________________________, the Owner or Renter do hereby
Name (Please Print)
request that the water service at the following vacant residence be transferred.
_____________________________________________________________________________________
Property Address
_____________________________________________________________________________________
Current Account Number Owner’s Telephone Number
_____________________________________________________________________________________
Date Service Should Be Transferred
_____________________________________________________________________________________
Transfer Address
Essential Information – Please Read and initial all lines
____ I understand that all water valves on the customer’s side of previous address should also be closed.
____ I understand that any prior charges must be paid in full before transfer will take place.
____ I understand that, after water service is transferred, there will be a final bill mailed the following
month to the above transferred address.
____ I understand that my water deposit of $ ______ will be transferred to the new address account.
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
