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2. This form should be used by title companies requesting property transfer, and should be submitted a minimum of two (2) business days prior to closing date. Inaccurate or incomplete information may delay processing time.
4. NOTE:
   EFFECTIVE JAN. 1, 2016 - A $40 TRANSFER CHARGE WILL BE ASSESSED. FAILURE TO NOTIFY US OF ANY CHANGES / CANCELLATIONS PRIOR TO SCHEDULED FINAL DATE WILL RESULT IN ADDITIONAL TRANSFER OF SERVICE CHARGES. Please remind your sellers NOT to pay their final bill as it is paid out of the escrow account.
6. Property address:*
8. Please select one of the choices below: *

   1. STATUS ONLY
   2. STATUS AND FINAL
   3. CHANGE - to change a previously submitted final read request
   4. CANCEL - to cancel a previously submitted final read request
9. THIS IS NOT A FINAL BILL.
11. Closing Date:*
13. Seller's name:*
15. Seller's Forwarding Address:*
17. City*
18. State*
19. Zip*
21. Title company:*
23. Requestor's Name:*
25. Requestor's Phone #:*
    xxx-xxx-xxxx
26. Requestor's Email Address:*
28. Mailing address for final bill:*
30. City*
31. State*
32. Zip*
34. Title company phone #:*
    xxx-xxx-xxxx
35. Title company fax number:
    xxx-xxx-xxxx
37. Buyer's name:*
38. Additional Buyer's name:
40. Buyer's phone #: *
    xxx-xxx-xxxx
    A valid phone number is required in order to process your request.
41. Buyer's alternate phone #:
    xxx-xxx-xxxx
    A valid phone number is required in order to process your request.
45. Buyer's email address:
47. Buyer:

    1. Will occupy

    1. Will not occupy
49. If buyer will not occupy, provide mailing address:
51. COMMENTS:
53. Please Note:
    Failure to pay final billing charges will result in additional late fees, service disconnection, assertion of a property lien and/or commencement of tax debt certification against the property.
57. For customer billing staff use only
    Actual final balance due may vary from current estimate. THIS IS NOT A FINAL BILL.
59. Date received
60. Date processed
61. Initials
63. Current balance
64. Previous outstanding balance(s) on premise
66. Date of last reading
67. Next billing date
69. Estimated escrow amount
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

* indicates a required field