2. Water Account Information Update*

   1. Yes

   I certify that the information I'm providing to the City of Derby Water Office is current and accurate.
4. Primary Name*
5. Social Security/Tax ID #
7. Co-Applicante Name
8. Social Security #
10. Home/ Cell #
11. Email Address
13. New Address*
15. Start Date:
17. Current/Previous Address
19. Disconnect Date
21. Electronic Signature (type your name)
23. Driver's License
25. Paperless Billing

    I authorize the City of Derby to electronically deliver my monthly bill to the e-mail address provided above. 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 e-mail until I cancel the paperless billing option. I understand that the Derby News monthly newsletter will be sent to me in a separate email from city staff.

26. Answer

    1. Yes
    2. No
28. ACH Payments

    Additional form required along with voided check.

29. Answer

    1. Yes
    2. No
30. Void Check
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