1

Property Information

 *

Property Address

2

Tenant Information

 *

Tenant Information

Tenant Name

Tenant Name

Tenant Name

3

Property Owner Information

 *

Property Owner Information

Property Owner Name	Property Owner Address
Property Owner Phone Number	Property Owner Email

4

I have read and understood the Town Ordinance Article IV, Section 74-421 (D) Billing and Responsibility for payment. The property owner is ultimately responsible for payment of all outstanding charges in accordance with Virginia Law (Section 15.2-5139, Code of Virginia).

Typing your name in the space below serves as your electronic signature.

 *

I have read and understood the Town Ordinance Article IV, Section 74-421 (D) Billing and Responsibility for payment. The property owner is ultimately responsible for payment of all outstanding charges in accordance with Virginia Law (Section 15.2-5139, Code of Virginia). Typing your name in the space below serves as your electronic signature.

Name

Date

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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