Owner Leave-On Request I will be responsible for electric, water, and / or sewer usage at the location(s) listed below. When a tenant moves out, these services will automatically be put into my name, provided that a normal request for disconnection has been requested. Note: If the tenant has been disconnected for non-payment, an attempt will be made by the Board of Public Works to contact the owner, provided they have given us a local phone number they can be contacted by. If, at this time, we are unable to contact the owner the services will remain off until the owner notifies the Board of Public Works. By signing this request, the property owner is responsible to contact the Board of Public Works if the property is sold, transferred, or vacated.Today's Date Customer Name*Customer Signature*Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number*Effective Date* Enter Service Location / Address Service Location / Address   Edit Delete There are no Entries. Add Entry CAPTCHA Service Location / Address This iframe contains the logic required to handle Ajax powered Gravity Forms.