Utility Bill Penalty Exempt Application

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Utility Bill Penalty Exempt Application

Please complete the below application to apply to waive the 5% penalty for the 2021 utility bills until the end of December 2021.

<form-template>
	<fields>
		<field type="text" subtype="text" required="true" label="Last Name" class="form-control text-input" name="text-1620925755245" value="Last Name"></field>
		<field type="text" subtype="text" required="true" label="First Name" class="form-control text-input" name="text-1620925753243" value="First Name"></field>
		<field type="text" subtype="text" required="true" label="House Number" class="form-control text-input" name="text-1620925751005" value="House Number"></field>
		<field type="text" subtype="text" required="true" label="Street Name" class="form-control text-input" name="text-1620925747899" value="Street Name"></field>
		<field type="radio-group" required="true" label="Utility Penalty Exempt" class="radio-group" name="radio-group-1620925741487">
			<option value="Yes" selected="true">Yes</option>
			<option value="No">No</option>
		</field>
		<field type="text" subtype="email" label="Email Address" class="form-control text-input" name="text-1620925733849" value="Email Address"></field>
		<field type="header" subtype="h3" label="FOIP" class="header"></field>
		<field type="paragraph" subtype="p" label="Personal information collected through this online form will be used for the sole purpose of processing the Utility/Tax Exempt Application with the Town of Blackfalds. This information is collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy Act (FOIP) and will be protected under Part 2 of the Act. If you have questions or concerns regarding the collection and/or use of this information, please contact the Records Management &amp;amp; FOIP Coordinator at 403-885-6370 or by email at foip@blackfalds.com." class="paragraph"></field>
		<field type="radio-group" required="true" label="Tax Penalty Exempt" class="radio-group" name="radio-group-1620925718323">
			<option value="Yes" selected="true">Yes</option>
			<option value="No">No</option>
		</field>
		<field type="textarea" label="Business Address (if applicable). Please list all addresses" class="form-control text-area" name="textarea-1620925703712" value="Business Address (if applicable). Please list all addresses"></field>
	</fields>
</form-template>