Date of request: *
Account Number:
Owners name: *
Service Address: *
Plat/Lot: *
Request for:
Closings($20.00):
Readings( $20.00):
Seasonal turn on/off ($40.00):
Water shutdown for service(varies):
All others (with explanation):
[all fees will be charged in accordance with the current RIPUC Rate Tariffs]
Provide a Reading & date taken/by whom:
Name of person requesting: *
E-mail address: *
Company:
Phone #: *
[for questions regarding this request]
Additional information:
[date needed, time requested etc]
If request pertains to a sale
New owner name:
New owner billing address:
City:
State - Zip: -
Response by Email [provide #’s]:
Response by Fax [provide #’s]:
Special Notes:

* REQUIRED FIELDS