2. Account Number
3. Date*
5. I would like the billing for water, sewer and trash removal for my property at:
7. Address*
9. City
10. State
11. Zip
13. To be mailed to:
15. First Name*
16. Last Name*
18. Address1*
20. City*
21. State*
22. Zip*
24. Tenant Phone Number
26. As owner of this property, I am responsible for these charges should the appointed person fail to pay. I understand that the person appointed above may remove their name from this billing by notifying the City of Durango directly.
28. Owner / Agent Name*
30. Address1*
32. City*
33. State*
34. Zip*
36. Phone Number
38. Owner / Agent Signature*
39. Electronic Signature*

    1. Check Box
41. In accordance with the Colorado Open Records Act, this submission and all related correspondence may be subject to public disclosure.
    * Please click the check box to validate an electronic signature. By checking this box, I am digitally signing this document. I agree to the terms stated in this document and further certify that checking this box counts as an electronic signature.
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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

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