City of Blythe
Vacant Property Request Form

Upon written request, the city may suspend billing for service for residential and or rental property when it will be uninhabited for a period of time in excess of sixty days. The written request must state a date to resume billing for service. The city may grant an extension of the suspended billing period upon written request stating a new date to resume billing for service and upon verification by the city that such property is still uninhabited.

Please use one form per request

Name:*

Phone Number:*

Service Address:*

Mailing Address:

City:*

State:*

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Zip Code*

Residence must be vacant at least 60 days

Start Date:

End Date:

Rental Property Vacant up to 60 Days

Start Date:

End Date:

30 Day Extension

Start Date:

End Date:

Signature:

Date:*

For City Use Only:

Account Number:

Reading:

Deposit No./Amount

Service Order No.:

Closing Bill:

Closed By:

Account Copy:

Palo Verde Disposal:

Service List: