SECTION B: INFORMATION ABOUT WATER & SEWER CHARGES PAID DURING THE CLASS PERIOD
List the address of the affected property below only if it is different from the Mailing Address provided above . Please submit a separate Claim Form for each Property for which you paid the City of Madison Heights for water and/or sewer service.
City
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Armed Forces - Africa, Canada, Europe, Middle East
Armed Forces - Americas
Armed Forces - Pacific
American Samoa
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Marshall Islands
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Puerto Rico
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State
Zip Code
Provide the period of time in which you paid stormwater charges to the City of Madison Heights:
+ Add Dates
If there are gaps within the period of time in which you paid stormwater charges to the City of Madison Heights, please attach a sheet listing the additional date range(s).