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2. Date
   Date
4. Address to Reinstate / Turn Off Service
6. Electronic Signature Agreement

   I hereby, hereby authorize the City of New Haven to reinstate/turn off services at the given address. I will not hold the City of New Haven or any of its agents responsible if there are any problems because of the reinstatement/disconnect of this water service.

   1. I agree.
8. Permissions

   1. I have given my permission for water to be shut off at the house.
   2. I have given my permission to turn water on at my own risk.
   3. See attached e-mail
10. Attachment
12. Electronic Signature
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14. 1. Receive an email copy of this form.
15. Email address

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16. Submit

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