DEP Authorization .pdf

File information

Original filename: DEP Authorization.pdf
Title: S A M P L E
Author: MccabeD

This PDF 1.6 document has been generated by Microsoft® Word 2013, and has been sent on on 14/12/2016 at 22:34, from IP address 64.38.x.x. The current document download page has been viewed 249 times.
File size: 83 KB (1 page).
Privacy: public file

Download original PDF file

DEP Authorization.pdf (PDF, 83 KB)

Share on social networks

Link to this file download page

Document preview

Property Owner’s Name: __________________________________________________________________
Owner’s Address: ________________________________________________________________________
Street Address
City, State and Zip
Owner’s Phone Number: ________________________ Email: ___________________________________
Account Number(s): ______________________________________________________________________
Service Address: ________________________________________________________________________
Street Address
City, State and Zip
Borough: __________________ Block: ___________


Name of Managing Agent or Representative: __________________________________________________
Managing Agent/Representative’s Address: ___________________________________________________
Street Address
City, State and Zip
Managing Agent/Representative’s Phone Number: ________________ Email: ______________________

To: New York City Department of Environmental Protection, Bureau of Customer Services
This letter confirms my/our designation of the above captioned individual or firm as my/our Representative to
act on my/our behalf in all matters concerning my/our New York City Water Board water/sewer account(s).
The Representative is hereby granted the right of access to information and the right to act as my/our agent
regarding our water and sewer billings for the accounts referenced above.
All contacts by the service provider are to be with and directed to the attention of the Representative.
However, this does not preclude my/our intervention. I/we understand that when releasing information to the
Representative the New York City Water Board or the New York City Department of Environmental
Protection has no authority to control the future use or dissemination of this information. Therefore, I/we
release the New York City Water Board, the New York City Department of Environmental Protection, the
City of New York and any officers, agents, or employees, thereof, from any and all liability that may arise out
of the Representative’s possession and the use of the information and records.
This written authorization is effective the date signed and will remain in effect for a TWO-YEAR period from
the date signed below.
Owner’s Name (Please Print)

Name of Person Signing (if different from Owner)

Relationship to Owner: ________________________________________

____________________________________ ________ Sworn before me
Owner’s Signature
Notary Signature: __________________________
Notary Public, State of New York
Qualified in ___________ County
Commission Expires _____________

Document preview DEP Authorization.pdf - page 1/1

Related documents

dep authorization
town of chester comprehensive 3 18 2015 complete
100a application to rent or lease
new city resident information
toe mo infrastructure 20170324

Link to this page

Permanent link

Use the permanent link to the download page to share your document on Facebook, Twitter, LinkedIn, or directly with a contact by e-Mail, Messenger, Whatsapp, Line..

Short link

Use the short link to share your document on Twitter or by text message (SMS)


Copy the following HTML code to share your document on a Website or Blog

QR Code

QR Code link to PDF file DEP Authorization.pdf