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* FOR LANDLORD USE ONLY * Application for Third-Party Notification of Utility Billing Notices
This form has been modified since it was saved. Please review all fields before submitting.
The City of Portage has the ability to send duplicate notices of utility billing mailings to property owners/landlords. The city can send duplicates of either original bills and/or delinquent notices (including shut-off notices). This is a free service that will become effective upon submission of the completed form. Please be aware that you will need to notify the Treasury Office if you sell the home or to cancel the third-party notification.
Address where utilities are received
Property Owner First Name
Property Owner Last Name
Driver License Number
Date of Birth
Date of Birth
Select the type of third party
Select one type only.
Other (please identify)
Please identify "Other"
Select the type of notification(s) you would like to receive
Select all that apply.
Delinquent notices (including shut off notices)
By signing this agreement, you initiate Third-Party Notification for Utility Billing Charges and indicate that you understand that you must cancel this authorization upon sale of the property.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
Treasury Staff only:
Location ID ________________
Processed by ______________
Checked by _______________
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