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Customer Registration Form For Water And Sewer Billing - New York Department Of Environmental Protection Page 2

Instructions for filling out this Customer Registration Form

(1)

Borough - Block - Lot and Meter Number: Enter the borough in which the premise is located followed by

the block and lot number. If the water meter number is available, provide this as well.

(2)

Service Address: Enter the address of the premise.

(3)

Mailing Address: Enter the address of the owner if different from the Service Address.

(4)

Owner’s Name: Enter the name of the business if the owner is a business. Enter the Last Name, First Name,

and Middle Initial of the owner if the owner is an individual.

(5)

Owner’s Telephone Number: Enter the owner’s home and business telephone numbers, including the area

codes.

(6)

Account Number: Enter the customer’s account number.

(7)

Customer Name: Enter the name of the individual or the business responsible for paying the water/sewer bills

for this premise.

(8)

Mailing Address: Enter the mailing address including the zip code of the individual or business responsible

for paying the water/sewer bills for this premise.

(9)

Relationship of customer to this premise: Check one option to identify the relationship of the customer to the

premise.

(10) Owner’s EIN or SSN: Enter the owner’s EIN (Employer Identification Number)if owner is a corporation or

partnership. Enter the owner’s SSN (Social Security Number) if the owner is an individual.

(11) Name and Title: Print the name and title (if applicable) of the corporate officer or owner who will sign this

form.

(12) Owner or Officer Signature: The owner or corporate officer must sign the registration form in order for it to

be valid. Please indicate the date the form is signed.

Important Information for New Property Owners

All new property owners must complete a Customer Registration Form. This will ensure water and sewer bills are

mailed to the customers who are responsible for making payments. Please make sure that the form is completed

accurately. Our Customer Service Representatives may be contacted at: (718) 595-7000 if you have questions

pertaining to the Customer Registration form or if you need assistance in completing this form.

PLEASE RETURN COMPLETED FORM TO:

Department of Environmental Protection

Bureau of Customer Services

Attn: Registration and Return Mail Unit

59-17 Junction Boulevard, 7

Floor

Corona, New York 11368-5107

Customer Registration Form For Water And Sewer Billing - New York Department Of Environmental Protection Page 2