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2. Stormwater fees are billed monthly.
4. Name of Applicant*
5. Phone Number*
7. Address*
8. City*
10. State*
11. Zip*
12. Is this the mailing address?*

    1. Yes
    2. No
14. Mailing Address

    * Required if mail is not delivered to home

16. Mailing City
17. Mailing State
18. Mailing Zip
20. Email Address*
22. Deposit
23. Closing/Service Date (This is the date that the property closed/purchased.)*
    Closing/Service Date (This is the date that the property closed/purchased.)

    Closing/Service Date (This is the date that the property closed/purchased.)
25. By paying with a check, you authorize us to make a one-time electronic debit from your bank or asset account for the amount of the check. For inquiries, please call 303-833-3291.
27. Deposit
    Deposit
28. Quantity
29. Shipping Cost
30. Taxable
32. A nonrefundable convenience fee for all online transactions will be added upon checkout.
34. Check Here

    1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
36. Signature*
37. Date*
    Date

39. The Town of Firestone will require account balances paid in full if water service is off. The customer requesting water to be reinstated will pay a reconnection fee and set an appointment one business day in advance to have water service reinstated.  The cut-off time is 4:30 p.m. daily for requesting reinstatement for the next business day.  All appointments will require someone to be present when the water is reinstated at the property.  Please contact Town Hall at 303-833-3291 to inquire about the status of the property entered above.

43. OFFICE USE ONLY
45. Received On:
46. By:
48. Approved On:
49. By:
51. Pymt. Type:
52. Amt. Paid:
53. Batch No:
55. Transaction No:
56. Date Paid:
57. Account Number:
Leave This Blank:


58. Calculate Totals Proceed to Checkout

* indicates a required field