Sign the Petition | Marion Water Action

RESIDENT STATEMENT & PETITION

Use this form to document your experience. Statements are collected to support a written request for records review and policy clarification relating to VA Code § 15.2-2121.3 and relevant local procedures.

Privacy: Your contact information is stored privately for verification and follow-up, and is not displayed on the public website. Please do not include sensitive personal information in your impact statement (e.g., SSN, banking details).

01. Identity (Stored Privately)

Full Name

Used only for verification and petition delivery.

Email Address

You may receive a “Signature Recorded” confirmation email.

Service Address in Marion

Address is used to match the service location and confirm residency for aggregation.

Customer/Account # (Optional)

Phone (Optional)

02. Disconnection Details

Disconnection Date (If known)

If you’re unsure, leave it blank.

Reconnection Fee / Penalty Amount (Optional)

I had not received my paper bill by mail before service was disconnected. I received no specific shutoff warning delivered by mail, door hanger, call, email, or text prior to disconnection. When I contacted the Town, I was told “It’s on your bill” as the primary explanation for notice. I was charged a reconnection fee and/or penalty that I believe may have been assessed in error.

If you did receive notice, how? (Optional)

If “Other,” you can explain in the impact statement below.

03. Impact Statement

Short Statement (Optional but helpful)

Please be factual and concise. Avoid sensitive personal details.

04. Authorization

I affirm that my statement is accurate to the best of my knowledge and reflects my personal experience. You may contact me for verification or follow-up questions about my statement.

By submitting, you authorize your statement to be compiled into a collective petition and records-review request to the Town. Your contact information remains private and is not displayed publicly.

If you have screenshots (billing ledger, fee receipt, USPS Informed Delivery), save them. You may be asked to provide them during verification.