I am requesting that my utility account be placed on the abandoned rate. I understand that in order to receive this rate, my water service will be discontinued (shut-off) and that my property can not have any water consumption during the time period listed below. The dates there will be no occupancy will be:*

to*

I understand that there will be no water service provided at this property and that the meter will be shut-off and locked. (Initials)*

I certify that there is no Fire Sprinkler attached to the water meter. (Initials)*

I understand I will need to contact the City five days before I want water service reconnected. (Initials)*

I understand that I must complete and submit this request prior to the account being placed on Abandoned Occupant Rate. (Initials)*

First and Last Name*

Service Address (98290 zip code only)*

Account Number

By submitting this application and entering my name below, I agree and acknowledge my electronic signature is valid and binding and contains the same force and effect as my handwritten signature. I acknowledge that the information submitted is true and correct and that I have authority to and I am authorized to submit and execute this application for Abandoned Occupant Utility Rates. By submitting this application for Abandoned Occupant Utility Rates, I acknowledge that the application for Abandoned Occupant Utility Rates is subject to suspension or revocation if false or misleading information is provided; and violation of any conditions and/or requirements of the Snohomish Municipal code or any permit conditions may result in the revocation of an Abandoned Occupant Utility Rates and the forfeiture of any fee paid.

First Name*

Last Name*

Email Address:

Date*