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2. Do you own the property?*

   1. Yes, I own the property.
   2. No, I do not own the property. I agree to complete the Utility Disconnection form and understand my online submission will not be accepted.

   Online submissions from renters will not be accepted. If you are renting the property, please complete the Utility Disconnection Form with all required signatures.

4. Name*
6. Phone Number*
7. Alternate Phone Number
9. Service Address*
11. Mailing Address*

    Your final bill will be mailed to this address.

13. Final Meter Reading (Move-Out) Date*
    Final Meter Reading (Move-Out) Date
15. Please choose one of the following as it applies:*

    1. I own the property and am selling, moving, or other.
    2. I do not own the property (Form will not be accepted online)

    If you are a renter or do not own the property you must complete a hard copy disconnection form with the property owner. Electronic forms will not be accepted for rental properties.

17. Do you want to have the water shut off at the street?

    1. Yes
    2. No

    Fees apply.
19. Unpaid bills are a lien on the property. Failure to receive bill does not waive penalty.*

    I agree I am responsible for any damages to the property of the City of Grand Ledge caused by my negligence. I agree to promptly pay any water/sewer bills, along with any fees I may incur. I understand failure to make timely payment may result in the City of Grand Ledge using all means permitted by law to collect the debt.

    1. I understand.
21. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Applicant Electronic Signature*
24. Date*
    Date
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field