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2. NOTE: THIS FORM IS TO BE COMPLETED ONLY BY THE LEGAL OWNER(S) OF THE PROPERTY REFERENCED BELOW. TENANTS/THIRD PARTIES, OR AGENTS OF THE OWNER(S), MAY NOT COMPLETE THIS FORM.
4. Water/Sewer Acct-Customer ID*
5. Property Tax ID #
6. Subdivision
8. Property Address*
10. City*
11. State*
12. Zip Code*
14. This authorization does not divide the normal quarterly water/sewer charges between the owner and tenant/third party. If an interim meter reading and bill to the property owner is desired, indicate the date the meter should be read. We will get a meter reading as close to that date as possible. I understand and agree to pay the $35.00 fee if an interim meter reading is requested. The fee will be added to the interim bill. Fees listed on this form are subject to change. Current charges for the fees listed on this form may be obtained at our website: https://www.frederickcountymd.gov/DocumentView.asp?DID=1106
15. Desired Meter Read Date
17. This authorization is valid and effective from the date processed until discontinued by the tenant, third party, property owner or until a new authorization form is received and processed by the Division of Water and Sewer Utilities (DWSU). To request an effective date in the future, enter that date in the box. Allow sufficient time for the DWSU to receive this authorization. (Note: The effective beginning date cannot be retroactive.)
18. Desired Effective Date
20. I, as owner, remain legally responsible for all outstanding balances as shown in the Office of the Treasurer of Frederick County. I acknowledge that in addition to ordinary means for collection of charges, including the discontinuation of water service to the property, the property may be sold at the Treasurer's annual tax sale to collect delinquent charges.
22. I understand there is a $20.00 charge to establish or modify this agreement, payment for which must be received by the DWSU prior to setup. Checks are to be made payable to "Treasurer of Frederick County" and sent to our local office at 4520 Metropolitan Ct., Frederick, MD 21704. To pay by debit or credit card, please contact our cashier at (301) 600-2182. (Note: A $2.00 service fee will be assessed for debit or credit card payments.) I also understand that there is a quarterly charge of $5.00, which will be included on the bill. I further understand that the account must not have a delinquent balance for the authorization to be processed.
24. The owner of the property will be mailed or e-mailed copies of the original water/sewer bill and late notice (if applicable).
26. Owner's Name*
27. Co-Owner's Name (if applicable)
29. If owner is not an individual, enter entity name and title of signatory:
31. Address of Owner*
    Street Address
32. Address of Owner*
    City, State, Zip
34. Owner's Phone No.*
35. Owner's E-Mail*
37. Name of Tenant/Third Party*
38. Address of Tenant/Third Party*
    Street Address
39. Address of Tenant/Third Party*
    City, State, Zip
41. Tenant/Third Party Phone No.*
42. Tenant/Third Party E-Mail*
43. Date Submitted*
45. By clicking on the Submit button below, I acknowledge that I am the property owner of the listed property and have read and agree to the terms and conditions shown above. I hereby request and authorize the Frederick County DWSU to send all water/sewer bills, correspondence, notices, etc. to the tenant/third party designated above.
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field