Customer Dispute Form
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1
2___________ Location Code
CUSTOMER DISPUTE FORM
(Borough office/web site/fax)
I
I
(P
P
A
S
F
)
DENTIFYING
NFORMATION
LEASE
RINT
LL
ECTIONS OF THIS
ORM
1.
Account Number (as it appears on your water bill)
2.
Customer Name_________________________________________________________________________
3.
(If known) Borough _______________________ Block ____________________ Lot _________________
4.
Mailing Address ________________________________________________________________________
5.
Home Tel (
) ________________________
Daytime Tel (
) __________________________
6.
Cell (
) ______________________ Email ________________________________________________
7.
Contact information of authorized representative of the owner (with Letter of Authorization), if
representative is filing the application or will represent the owner at a review meeting:
•
Name __________________________________________________________________________
•
Mailing Address __________________________________________________________________
•
Home Tel (
) _______________________
Daytime Tel (
) ________________________
•
Email ___________________________________________________________________________
8. Service address (location of property), if different than the owner’s mailing address:
___________________________________________________________________________
9. Type of property (check one):
[
] Residential
[
] Commercial
[
] Industrial
[
] Vacant Land
[
] Mixed Use
[
] Other (List Type): _____________
G
D
(P
P
A
S
F
)
ROUNDS FOR
ISPUTE
LEASE
RINT
LL
ECTIONS OF THIS
ORM
Categories (check all that apply)
Amount in Dispute
[
] High Bill
[
] Estimated Bill
[
] Interest Charges
[
] Remittance/Refunds
[
] Program Application Denial
[
] Other (List Type): _____________
Type of Dispute
[
] Complaint (check if this is your first filing for this issue)
[
] Initial appeal (check if you would like to appeal the DEP BCS response to your complaint)
Briefly state the grounds or basis upon which you believe the water and/or sewer charges are incorrect. Attach
additional sheets or documentation, if necessary.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I certify that all statements made on this application are true and correct to the best of my knowledge and belief, and I understand that the
making of any willful false statement of material fact herein will subject me to the provisions of the Penal Law relevant to the making and filing
of false instruments.
Signature of the Owner
Signature of Authorized Representative
Printed Name of the Owner
Printed Name of Authorized Representative
Date
Date
[
] Check here if Letter of authorization is on file. Authorized representative must file a notarized Letter of Authorization
Submit Completed Form to: DEP/Customers Service, P.O. Box 739055, Elmhurst, NY 11373-9055
FOR INTERNAL USE ONLY:
Intake Date: ___/____/_____
Taken By: ______________
Unit: ________________
Referral #_____________________
Scan Date: ___/____/_____
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Parent category: Legal