Deposit Refund Request

I certify that I am the owner/occupant of residence located at __________________________

____________, and I am requesting refund of any utility deposits I have on file with the City of LaFayette.  I understand that these deposits will be applied to my utility bill.  I further certify that I have not been delinquent during the past 12 months.

Account# __________________                 Signature _________________________                   

Deposit amount ______________                Date ____________________________