Water Shut-Off Request

You may email your request to shut off services to j.hayward@galenaks.gov or drop it off at 211 W 7th St, Galena, Kansas 66739. Please make sure you have filled out the form in its entirety. Your final bill or refund will be mailed to your forwarding address. Final bills will need to be paid within 90 days or they will be turned over to Collection Bureau of Kansas for debt collection. For more information please contact the clerks office at 620-783-5265 ext. 1.

Water Shut Off Request

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Account Holder Name *

First

Last

Account Address *

Address Line 1

Address Line 2

City

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Zip Code

Phone

Email *

Forwarding Address *

Address Line 1

Address Line 2

City

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Zip Code

Picture Identification Required *

Drag & Drop Files, Choose Files to Upload

Please upload or attach photo Identification for account holder.

By checking each box you are confirming to the following *

• I understand that all water valves on the customer’s side of the line should also be closed.
• I understand that any prior charges must be paid and that penalty and interest will accrue on any unpaid charges.
• I understand that, after water service is terminated, there will be a final bill mailed the following month to the above forwarding address
• I understand that my water deposit will be applied to the final bill.

Required Email are

Comment or Message

Signature

The undersigned Owner or Renter of the property hereby releases The City of Galena, including its offices, employees and agents from any and all liability related to the termination of water service, the failure to terminate water service or the restoration of water service at the address shown above.

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