customer-dispute-form.pdf

IDENTIFYING INFORMATION (PLEASE PRINT ALL SECTIONS OF THIS FORM)

1. Account Number (as it appears on your water bill)

2. Customer Name_________________________________________________________________________

3. (If known) Borough _______________________ Block ____________________ Lot _________________

4. Mailing Address ________________________________________________________________________

5. Home Tel ( ) ________________________ Daytime Tel ( ) __________________________

6. Cell ( ) ______________________ Email ________________________________________________

7. 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:

• Name __________________________________________________________________________

• Mailing Address __________________________________________________________________

• Home Tel ( ) _______________________ Daytime Tel ( ) ________________________

• Email ___________________________________________________________________________

8. Service address (location of property), if different than the owner’s mailing address:

___________________________________________________________________________

9. Type of property (check one):

[ ] Residential [ ] Commercial [ ] Industrial [ ] Vacant Land

[ ] Mixed Use [ ] Other (List Type): _____________

ROUNDS FOR DISPUTE (PLEASE PRINT ALL SECTIONS OF THIS FORM)

Categories (check all that apply) Amount in Dispute

[ ] High Bill [ ] Estimated Bill [ ] Interest Charges

[ ] Remittance/Refunds [ ] Program Application Denial [ ] Other (List Type): _____________

Type of Dispute

[ ] Complaint (check if this is your first filing for this issue)

[ ] Initial appeal (check if you would like to appeal the DEP BCS response to your complaint)

Briefly state the grounds or basis upon which you believe the water and/or wastewater charges are incorrect.

Attach additional sheets or documentation, if necessary.

__________________________________________________________________________________________

_______

___________________________________________________________________________________

I 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.

Signature of the Owner

Signature of Authorized Representative

Printed Name of the Owner

Printed Name of Authorized Representative

Date

[ ] Check here if Letter of authorization is on file. Authorized representative must file a notarized Letter of Authorization

CUSTOMER DISPUTE FORM

___________ Location Code

(Borough office/web site/fax)

Submit Completed Form to: DEP/Customers Service, P.O. Box 739055, Elmhurst, NY 11373-9055

FOR INTERNAL USE ONLY:

Intake Date: ___/____/_____ Taken By: ______________ Unit: ________________

Referral #_____________________ Scan Date: ___/____/_____

HOW TO COMPLETE THIS FORM

This form must be completed by the owner or an Authorized Representative. If you are not authorized to

cess this account, you must file a Letter of Authorization with DEP

Complete the entire form, including the account information and complaint description. Describe the issue as fully

as possible

Sign and date the form

Attach any additional documentation if desired. All additional documentation will be retained by DEP

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

How to submit this form

You may submit this form at any BCS borough office

You may mail this form to: DEP/BCS Customer Service, P.O. Box 739055, Elmhurst, NY 11373-9055

You may email this form to: customerservice@dep.nyc.gov; in the subject field note if this is the first time you are

Disputing this issue by stating (Dispute) or if this is an Initial Appeal of the DEP response you have received, by

stating (Initial Appeal)

Please note, DEP no longer a

ccept fax submissions.

You may submit a dispute online using your My DEP Account. To learn more, visit nyc.gov/dep

Please use this extra space for writing…… (Attach additional paper as needed)

Dispute Form Back 8-8-2022

About the written complaint process

You have the right to file a formal dispute of a disputed water and wastewater bill with the Department of

Environmental 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 decision within 90 days of receipt of the complaint.

The regulations and appeal process can be viewed online at https://www1.nyc.gov/assets/dep/downloads/pdf/pay-

my-bills/customer-service/dispute-resolution-process-overview.pdf, or a copy can be mailed to you by calling

718-595-7000, Monday, 8:00am to 7:00pm; Tuesday to Friday, 8:00am to 6:00pm; Saturday, 9:00am to 12:00pm.