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Account Number: Date: NOTICE OF TEMPORARY VACANCY Effective Date: Re-Occupy Name: Current and /or Mailing Address: Service Address: Reason for Vacancy: I hereby notify the City of Blackfoot that the above service address is in my name and will be vacant for a minimum of 30 days (1 month), but vacant not more than 90 days (3 months). I understand that the Utility Billing Department must be contacted at the end of the three months if I need to extend this vacancy. I understand that the garbage receptacle(s) must be made available for pick up by the Sanitation Department, resulting in no garbage charges from the effective date on this form until such time the Utility Billing Department is notified that the property is no longer vacant, or the estimated re- occupy date has past, at which time the Sanitation Department will be notified to redeliver the garbage receptacle to the property. I understand that if the vacancy occurred prior to the receipt of this form, the effective date will be the receipt date. I further understand that unless the garbage receptacle is/are not physically removed from the property by the Sanitation Department, garbage charges will continue. I also understand that failure to contact the Utility Billing Department, prior to re-occupy date for redelivery, will result in automatic redelivery of the garbage receptacle and charges for garbage will resume. Signed: Date: (Owner/Manager) Processed by: Date: (Utility Billing Representative)