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2. Resident Name:*
   As it shows on bill
4. Resident Service Address*
   City, state, and zip not required
6. Mailing Address
   If different from service address
8. Primary Phone #*
9. Secondary Phone #
10. Utility Account No:*
12. Email Address:*
14. Electronic signature*
    By typing your name into this field this form, you understand that the information given above will be used to consider your late fee waiver request. You are agreeing that the information given to the City is correct.
15. Date*
    Date
17. Contact Us
    • Utility Billing: 713.662.5824
    • Customer Service: 713.662.5826
    • Direct Link: 713.662.5860
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

* indicates a required field