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Utility Service Account Change Form

2. City of Bainbridge Island - Utility Service Change Form

   Use this form if you are starting or stopping utility service at an established, existing service address.

   Once the following information is submitted, Utility Billing will contact you at the contact information provided to confirm the change to service. If you have questions, please contact Utility Billing at (206) 780-8603 or finance@bainbridgewa.gov.

   Note: If you need to set up a new billing account for a service address that is not an established, existing service address (for example, if the service address is part of a new development), please complete a New Utility Connection application.

4. Section I. Change Information
   Complete the following fields to start or stop utility service at an established, existing service address.
6. Date of Change:*
   Date of Change:
   Please indicate the date the change is to be effective.
7. Type of Change Requested:

   1. Start Service
   2. Stop Service

   Please select if you want to start or stop utility service.
9. Who is completing the change form?*
   -- Select One --Property OwnerTenant
11. Property Owner 1 - First Name (if applicable)
12. Property Owner 1 - Last Name (if applicable)
14. Property Owner 2 - First Name (if applicable)

    (Owners are copied on delinquent accounts.)

15. Property Owner 2 - Last Name (if applicable)
17. Tenant 1 - First Name (if applicable)
18. Tenant 1 - Last Name (if applicable)
20. Tenant 2 - First Name (if applicable)
21. Tenant 2 - Last Name (if applicable)
23. Service Address:*
    Please enter the address address of the property receiving utility service. Note: All service addresses are on Bainbridge Island.
25. Section II. Billing/Forwarding Information
27. Mailing Address*
    A mailing address for billing/final billing is required.
29. City*
30. State*
31. Zip*
33. Email Address 1
    Please provide an email address for your account.
34. Email Address 2
    Optional: If you prefer, you may connect a second email address to your account.
36. Phone Number 1*
    One valid phone number is required to set up your account.
37. Phone Number 2
    Optional: If you prefer, you may connect a second phone number to your account.
39. Comments
    Use this space to include any comments, questions, or instructions to Utility Billing.
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field