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2. Opt In to the Valpo Tree Fund Donation Program

   Fill out the form below to start the process to opt in to this program.

   After submitting, keep an eye out within the next month for the "City Tree Fund" line item to appear on your monthly Utility bill.

   This will remain on your monthly bill until you cancel. To cancel, call the Utilities office at (219) 462-6174.

   Learn more about the program or find more details on the Valpo Parks website.

4. Account Holder First Name*
5. Account Holder Last Name*
7. Utilities Account Number*

   This is the account that you use to pay for Trash, Water and Sewer bills.

9. Address*
11. Address Line 2
13. City*
14. State*
15. Zip Code*
17. Phone Number*
19. Monthly Donation Amount:*

    1. $1
    2. $5
    3. $10
    4. Other (write-in)
20. Other Amount (Round Numbers Only)*
22. Signature*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree
24. Signature*
25. Date*
    Date
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field