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4. Instructions

   Please fill out the form below if you would like to request snowbird status. Please give one business day notice for turn on/turn off request.

6. Customer # - Account Number #
   Located on Statement
8. First Name*
9. Last Name*
11. Service Address *
13. City
    Lafayette
14. State
    Indiana
16. Main Contact Phone Number*
17. Alternate Phone Number
19. Date Requested:
    Date Requested:
    *Next Business Day
20. Requested Service*
    -- Select One --Turn Off WaterTurn On Water
22. Billing Address, If Different from Service Address
24. Billing Address Line 2
26. City
27. State
28. Zip
30. Additional Information:
    If you would like to request a specific time or leave any additional notes
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