Rate Change Account Impact Summary Form

Burlington Water Resources has proposed changes to the rate structure that will become effective July 1, 2021 - and will be first reflected in bills received in August 2021. As part of this initiative, we have created a model using consumption data from 2019 to calculate the estimate financial impacts for each customer.

Please complete the form below, and our staff will provide an estimate of the financial projections for your account within 10 business days of your submittal.

Page 1 of 2

Requestor Name *

Affiliation to Property *

Business Name (if applicable)

Mailing Address *

Email Address *

Phone (if additional information is needed) *

IF YOU ARE THE PROPERTY OWNER PLEASE SKIP TO PROPERTY LOCATION INFORMATION!

Property Owner Name *

Property Owner Address *

Property Owner email *

Property Owner Phone *

The following fields are required.

Property Location Address *

Property Type *

Water Account Number *

Does the property have a fire service line? *

Yes

If you have a fire service, please specify the diameter of that pipe (inches)

Does the property have an irrigation meter? *

Yes

Rate Change Account Impact Summary Form

Contact DPW