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Account Number (as it appears on your water bill)  \n2. Customer Name   \n3. (If known) Borough   Block   Lot    \n4. Mailing Address    \n5. Home Tel ( )   Daytime Tel ( )    \n6. Cell ( )   Email    \n7. Contact information of authorized representative of the owner (with Letter of Authorization) , if representative is filing the application or will represent the owner at a review meeting:  \n• Name    \n• Mailing Address    \n• Home Tel ( )   Daytime Tel ( )    \n• Email    \n8. Service address (location of property), if different than the owner’s mailing address:  \n___________________________________________________________________________  \n9. Type of property (check one):  \n[ ] Residential [ ] Commercial [ ] Industrial [ ] Vacant Land  \n[ ] Mixed Use [ ] Other (List Type):    \nGROUNDS FOR DISPUTE (PLEASE PRINT ALL SECTIONS OF THIS FORM)  \nCategories (check all that apply) Amount in Dispute  \n[ ] High Bill [ ] Estimated Bill [ ] Interest Charges  \n[ ] Remittance/Refunds [ ] Program Application Denial [ ] Other (List Type):    \nType of Dispute  \n[ ] Complaint (check if this is your first filing for this issue)  \n[ ] Initial appeal (check if you would like to appeal the DEP BCS response to your complaint)  \nBriefly state the grounds or basis upon which you believe the water and/or wastewater charges are incorrect. Attach additional sheets or documentation, if necessary.  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n|  |\n\nI certify that all statements made on this application are true and correct to the best of my knowledge and belief, and I understand that the making of any willful false statement of material fact herein will subject me to the provisions of the Penal Law relevant to the making and filing of false instruments.  \n\n| Signature of the Owner |\n| --- |\n| Printed Name of the Owner |\n\n\n| Signature of Authorized Representative |\n| --- |\n| Printed Name of Authorized Representative |\n\nDate Date  \n[ ] Check here if Letter of authorization is on file. Authorized representative must file a notarized Letter of Authorization  \nHOW TO COMPLETE THIS FORM  \n\n| 1. This form must be completed by the owner or an Authorized Representative. If you are not authorized to access this account, you must file a Letter of Authorization with DEP\u003Cbr>2. Complete the entire form, including the account information and complaint description. Describe the issue as fully as possible\u003Cbr>3. Sign and date the form\u003Cbr>4. Attach any additional documentation if desired. All additional documentation will be retained by DEP\u003Cbr>5. If you would like copies of the additional documentation, please make them before submitting the form. DEP will only provide copies of the original form as a receipt of your complaint |  |  |\n| --- | --- | --- |\n| How to submit this form\u003Cbr>1. You may submit this form at any BCS borough office |  |  |\n| 2. You may mail this form to: DEP/BCS Customer Service, P.O. Box 739055, Elmhurst, NY 11373-9055 |  |  |\n| 3. | You may email this form to: [customerservice@dep.nyc.gov](customerservice@dep.nyc.gov) ; Disputing this issue by stating (Dispute) or if this is an Initial stating ( Initial Appeal)\u003Cbr>Please note, DEP no longer accept fax submissions. | in the subject field note if this is the first time you are Appeal of the DEP response you have received, by |\n| 4. | You may submit a dispute online using your My DEP Accou | nt. To learn more, visit [nyc.gov/dep](nyc.gov/dep) |\n| Please use this extra space for writing…… |  | (Attach additional paper as needed) |\n\n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n|  |\n\nAbout the written complaint process  \nYou have the right to file a formal dispute of a disputed water and wastewater bill with the Department of  \nEnvironmental Protection. Disputes must be submitted in writing within four years of the date of the bill in question. DEP will make best efforts to render a written dec","cbCaisS9nAG4qpZ9","https://ap.wps.com/l/cbCaisS9nAG4qpZ9","pdf",298179,"English","# Identifying information\n# Grounds for dispute\n# How to complete this form\n# How to submit this form\n# About the written complaint process","[{\"question\":\"谁可以填写并提交这份争议表单？\",\"answer\":\"表单必须由业主或获授权代表填写。如果代表需要访问该账户，需提交授权函（并按要求提供公证的授权函）。\"},{\"question\":\"争议类别有哪些选择？\",\"answer\":\"可勾选与争议金额或原因相关的类别，例如高额账单、预估账单、利息费用、退款/汇款、项目申请被拒等，也可在其他栏填写具体类型。\"},{\"question\":\"如何提交争议申请以及需要在什么时间内提交？\",\"answer\":\"表单可在各BCS行政办公室提交、邮寄或通过My DEP Account在线提交。书面争议必须在涉案账单日期后的四年内提交。\"}]","Customer Dispute Form - Customer water and wastewater billing dispute request | PDF",1789518399]