This form is to assist the Mississippi Public Service Commission identify gaps in water service across our state.

Prefix First Name * Last Name * Suffix

Physical Address 1 *

Physical Address 2

City * State Zip *

Mailing Address 1 *

Mailing Address 2

City * State Zip * County *

Primary Phone Number * Secondary Phone Number

Email Address (Please complete if you would like a confirmation email)

Do you currently have water to your home?
If yes, who provides your service?

If you are planning new construction and need water service at that location, please provide the complete address below.

New Construction - Address 1

New Construction - Address 2

City State Zip

Please provide any details that may be helpful in providing water service to your home.