2. Town of Platteville
   400 Grand Avenue Platteville, CO 80651 970-785-2245 970-785-2476 (fax)
5. Utility Billing Appeal Request Form
   If payment in full is not received by the Town on or before the 3rd Tuesday of the month in which the charges were billed, they shall be deemed delinquent. To avoid disconnection of services, the following appeals process has been initiated to allow citizens an opportunity to request alternatives regarding suspension or termination of the account on the 4th Tuesday of the month.
7. First Name*
8. Last Name*
10. Account Number*
12. Service Address*
14. City*
15. State*
16. Zip*
18. Home Phone
19. Cell Phone*
21. Email*
25. Total Amount Due*
26. Proposed Payment Date*
    Proposed Payment Date
28. Reason for Delinquency*
32. Renters / Lessees
34. Owner's First Name*
35. Owner's Last Name*
37. Owner Address
39. City
40. State
41. Zip
43. Owner's Home Phone
44. Owner's Cell Phone
53. Owner / Tenant Signature
54. Date of Signature
    Date of Signature
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field