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2. LEAD SERVICE LINE REPLACEMENT REFUSAL

4. The Customer does NOT elect for the City of Bluffton, Indiana (“City”) to replace Customer’s lead water service line: 

   Customer Acknowledgement

   The undersigned customer(s), whose name(s) appear(s) in the signature block shown below (the  “Customer”), who receives water service provided by the City to the residence at the Property address listed below, acknowledges that the Customer has been informed by the City that the Customer-owned water service line is made of lead pipe, i.e., that portion of the water service line running from the City’s water meter into the Customer’s home (the Customer’s “Connecting Line”). The Customer acknowledges that the Customer elects not to authorize the City to replace the Customer’s Connecting Line. The Customer also acknowledges that Customer has received and read the “Important Notice About Your Water Service Line,” “Material Notification – Lead Discovered” information sheets provided by the City.

6. Property Street Address:*
7. City*
8. Zip Code*
10. Customer Name:*
11. Customer Phone Number:*
13. Customer Email:*
17. 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.

    1. I agree.
19. Property Owner's Signature:*
20. Date:*
    Date:
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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