1

First Name

 *

First Name

2

Last Name

 *

Last Name

3

Property Address

 *

Property Address

4

Account Number

 *

(Please Include Hyphen, I.E. XXXXXXX-XXX)

5

Water Meter Reading:

 *

X X X X X X 0

6

Date of Read

 *

Date (mm/dd/yyyy)

7

Email Address

 *

Email Address

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