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The City of New York

Department of Environmental Protection

Bureau of Customer Services

59-17 Junction Boulevard

Corona, NY 11368-5107

Customer Registration Form for Water and Sewer Billing

Property and Owner Information:

(1) Property receiving service is located in the Borough of __________________________________________

Block:

Lot:

Meter Number (if available):

(2) Street Address of Property Receiving Service:

Street __________________________________ City ________________________ State ________ Zip ___________

(3) Full name, mailing address and telephone/fax number of owner of property receiving service

(please provide information on owner ONLY; do NOT give information on property manager or tenant):

Owner’s Name

Business:_________________________________________________________________________

or Individual: __________________________

________________________

______________

(Last Name)

(First Name)

(MI)

Street __________________________________ City ________________________ State ________ Zip ___________

Telephone ( ______ ) ______________________________ Fax ( ______ ) _____________________________________

Customer Billing Information

PLEASE NOTE:

A. WATER AND SEWER CHARGES ARE THE LEGAL RESPONSIBILITY OF THE OWNER OF A PROPERTY RECEIVING

WATER AND/OR SEWER SERVICE. THE OWNER’S RESPONSIBILITY TO PAY SUCH CHARGES IS NOT AFFECTED BY

ANY LEASE, LICENSE OR OTHER ARRANGEMENT, OR ANY ASSIGNMENT OF RESPONSIBILITY FOR PAYMENT OF

SUCH CHARGES.

B. WATER AND SEWER CHARGES CONSTITUTE A LIEN ON THE PROPERTY UNTIL PAID. IN ADDITION TO LEGAL

ACTION AGAINST THE OWNER, A FAILURE TO PAY SUCH CHARGES WHEN DUE MAY RESULT IN FORECLOSURE

OF THE LIEN BY THE CITY OF NEW YORK, OR THE PROPERTY BEING PLACED IN A LIEN SALE BY THE CITY.

C. ORIGINAL BILLS FOR WATER AND/OR SEWER SERVICE WILL BE MAILED TO THE OWNER, AT THE OWNER’S

ADDRESS SPECIFIED ON THIS FORM. DEP WILL PROVIDE A DUPLICATE COPY OF BILLS TO ONE OTHER PARTY

(SUCH AS A MANAGING AGENT) IF SO REQUESTED BELOW, PROVIDED, HOWEVER, THAT ANY FAILURE OR DELAY

BY DEP IN PROVIDING DUPLICATE COPIES OF BILLS SHALL IN NO WAY RELIEVE THE OWNER FROM HIS/HER/ITS

LIABILITY TO PAY ALL OUTSTANDING WATER AND SEWER CHARGES.

(4) If you would like a duplicate copy of bills sent to another party, please check here ______ and fill out the following information:

Name of Party to Receive Duplicate Copies of Bills: ________________________________________________________

(5) Mailing Address: Street __________________________ City __________________ State ________ Zip ___________

(6) Account Number (if applicable): _______________________________________________________________________

(7) Relationship to Owner (check one): Managing Agent ___________________

Mortgagee ________________________

Tenant _________________ Other (please explain): ________________________

Owner’s Approval

The undersigned certifies that he/she/it is the owner of the property receiving service referenced above; that he/she/it has read

and understands Paragraphs A, B, C under the section captioned “Customer Billing Information”; and that the information sup-

plied by the undersigned on this form is true and complete to the best of his/her/its knowledge.

(8)

Owner’s EIN or SSN: _______________________________________________________________________________

(9)

Name of Owner: ___________________________________________________________________________________

(10) Signature: ________________________________________________________________________________________

Name and Title of Person Signing for Owner, if applicable: __________________________________________________

(11) Date: ____________________________________________________________________________________________

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

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