Water & Sewer Relief Form

There are two options to submit your Water & Sewer Relief Form.

 

1. Download and Print the Following PDF Application form, then drop it off or mail it to our office.

OR

2. Complete and Submit the Following Form Online and someone from our office will contact you to make payment arrangements.

GLOVERSVILLE-JOHNSTOWN WASTEWATER TREATMENT FACILITY REQUEST FOR ADMINISTRATIVE REVIEW OF WATER/SEWER BILL RESIDENTIAL/COMMERCIAL
Name: Email (Optional): Address : Phone : Address of Property for which this review is requested: Type of Property: Single Family Home Two Family Home Other Please describe the unusual circumstances or reasons why an adjustment of the sewer bill is requested: Describe actions taken to correct problem I certify under penalty of the law that the request and all attachments were prepared under my direction or supervision and are true under the penalties of perjury. I understand that all statements made me and connection with this request are subject to investigation and certification. I am aware that a false statement made herein is punishable as a Class A misdemeanor pursuant to section 210.45 New York State penal law. That by signing this request form, I understand that I am hereby consenting to granting access to my premises for physical inspection upon reasonable notice by any City official or representative of the Gloversville - Johnstown joint wastewater treatment facility in order to investigate the substance or basis of this request for administrative review. Failure to provide the aforesaid requested access will result in denial of said request for administrative review of sewer bill.
Customer Signature:	Date:

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