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Refund Request (Utility Billing)

  1. Customer Information
    Please read and complete the information below. Utility Billing can be reached at 407-703-1727.
  2. First and Last Name
  3. Mailing address
  4. Please indicate an amount.
  5. Please indicate the account for this refund request.
  6. Address for this refund request.
  7. Please indicate the reason for the request.
  8. Request Acknowledgment
    As the customer and/or owner for the above listed service address, I hereby notify the City of Apopka Utility Billing Department that I request a refund as listed above. By signing this claim form, I certify that all the facts and figures are true and complete to the best of my knowledge, and that no such refund has been previously claimed or received by me for the period covered by this claim.
  9. 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.
  10. Please type your full name.
  11. Leave This Blank:

  12. This field is not part of the form submission.