2. Paperless Billing Authorization Form*

   1. Yes

   I authorize the City of Derby to electronically deliver my monthly water and sewer bill to my email. I understand that it is my responsibility to contact the City if I do not receive my bill by the billing date each month. If a payment is received after the due date, penalties will apply. Billing statements will be delivered only via email until I cancel the paperless billing option in writing.
4. First Name*
5. Last Name*
7. Account Number
9. Service Address*
11. Email Address*
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13. 1. Receive an email copy of this form.
14. Email address

    This field is not part of the form submission.

15. Submit

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