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2. 
3. SEASONAL SHUT OFF AND ON FORM
5. NAME ON ACCOUNT*
7. WATER/SEWER ACCOUNT NUMBER*
9. SERVICE ADDRESS*
11. EMAIL
13. SHUT OFF DATE*
    SHUT OFF DATE
    No weekends or holidays
14. TURN ON DATE*
    TURN ON DATE
    No weekends or holidays

16. I acknowledge that the City will retain any security deposit on my account during the seasonal discontinuance and that upon my return, I will be required to pay a service charge fee of $30.00 as set forth in Section 58-94 of the City of West Melbourne Code of Ordinances. The seasonal discontinuance of service shall be granted for a period not shorter than two months or longer than six months. Monthly charges totaling $13.66 (water $7.10, sewer $6.00 and $0.56 utility tax) shall be billed to my account. For those customers that have reuse available, the $16.69 monthly fee will also be billed.

18. SIGNATURE OF ACCOUNT HOLDER*
    Type your name
19. TODAY'S DATE*
    TODAY'S DATE
21. MAILING ADDRESS:
23. STREET ADDRESS*
24. CITY, STATE, ZIP*
26. CURRENT PHONE NUMBER*
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

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