Water Survey


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 is you would like aConfitmation 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.