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2. City of Burlington
   Utility Billing Change of Service Form
4. Property Address
5. Effective Date
7. Change of :*

   1. Ownership
   2. Business Ownership

   1. Billing Address

   1. Renter

   1. Copy to Renter
9. Number of Occupants:
11. Name / To
12. Phone
14. Mailing Address
16. City
17. State
18. Zip
20. Name / From
21. Phone
23. Forwarding Address
25. City
26. State
27. Zip
37. Billing periods are: Jan/Feb, Mar/Apr, May/June, July/Aug, Sep/Oct, Nov/Dec.
    Sewer and Storm Drain billing is done bimonthly. Changes occurring within a billing period will be pro-rated by the day.
39. Senior Discount Rate
    Senior rates for Waste Management are available for those 62 and over. If you are eligible please contact City Hall Finance Dept at 360-755-2377.
43. Signature*
44. E-mail Address:*
46. Date*
50. FM
51. Date
52. Taken By
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field