Owner Release for Utilities

2. Account Number

3. Date*

5. I would like the billing for water, sewer and trash removal for my property at:

   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:

    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.

    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.

    * 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

* indicates a required field