Required fields are marked with asterisks (*)

Permission to Share Information

I give the City of Belleville permission to share details about my Water & Wastewater account with the person(s) or organization(s) listed below. This could include, for example, an OW/ODSP caseworker, a trustee or Power of Attorney, a lawyer, a family member, or other support person.

I understand that this permission allows these supports to help me with questions or issues related to my utility account. I also understand that I may withdraw this permission at any time by providing written notice.

Support One

Full Name of Support Person:

Relation to You:

Organization (if applicable):

Phone Number:

Email:

Support Two

Full Name of Support Person:

Relation to You:

Organization (if applicable):

Phone Number:

Email:

Support Three

Full Name of Support Person:

Relation to You:

Organization (if applicable):

Phone Number:

Email:

Declaration

I understand the purpose for disclosing this personal information to the person(s)/organization(s) noted above. I understand that I can withdraw this consent at any time by providing written notice.

Your Name:

Utility Billing Account # (11 digits):

Date:

Signature

Clear

Privacy Notice

The personal information on this form is collected by the City of Belleville under the authority of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56, and will be used by Water Finance staff to administer your Water & Wastewater account and for other related administrative purposes.

For assistance, or further information please call 613-966-3657 ext. 2243 or email watercollections@belleville.ca.