2. Account No.:*
3. Effective Date:*
5. Name on Account:*
6. Return Date:*
   (Notification is required to re-establish suspended service)
8. Email Address or Phone Number:*
   (For Verification)
9. More Than 5 Days Notice*

   (Refer to Agreement items)

   1. Yes
   2. No
11. Service Address:*
13. Services:*

    1. Water/Wastewater Service (does not include non-metered irrigation) - $10.00 per request
    2. Electric Service - $25.00 per request (non-remote); No charge for remote
    3. Sanitation Service – No charge if container remains on property and not serviced
    4. Fiber Service- No service fee (you will still need to contact your internet provider separately)
15. Services (Double Fee):*

    (Fees are doubled due to inefficient notice)

    1. Water/Wastewater Service (does not include non-metered irrigation) - $20.00 per request
    2. Electric Service - $50.00 per request (non-remote); No charge for remote
    3. Sanitation Service – No charge if container remains on property and not serviced
    4. Fiber Service- No service fee (you will still need to contact your internet provider separately)
17. Aggreement:
    1. I hereby notify the City of Idaho Falls that the above service address and account is in my name and will be vacant for a minimum of three weeks (21 calendar days), but vacant not more than six months (180 calendar days). I understand Utility billing must be contacted within five (5) business days prior to the end of the period should I need to extend this vacancy.
19. 2. I understand any utilities identified as selected above will be suspended during the effective and return date. I further understand that if the water service is not suspended during the effective and return date, there will be no credit for non-metered irrigation and wastewater charges.
21. 3. I understand in the event I request a suspension of water services, I agree to winterize my property at my own expense.
23. 4. I understand that I must notify Utility billing at (208)612-8280 within five (5) business days (Monday-Friday, 8:00 am to 5:00 pm) of the time this property is occupied again and that failure to notify may result in the back billing of all utility charges from the effective date of this notice.
25. 5. I understand there is a cost of providing this service and my account will be charged a service fee for the requested service listed above per request during regular business hours (Monday – Friday, 8:00 am to 5:00 pm). I further understand that a request after business hours identified above will be subject to an after-hours call out of service and charged a fee of double the requested service per request.
27. 6. I agree to hold the City of Idaho Falls harmless of any liability claim(s) or damage to my property other than caused by City negligence as the result of this request.
29. Signed:*
    Property owner or authorized designee
30. Date:*
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field