* Denotes a Required Field MUNICIPALITY/MEMBER INFORMATION Municipality/ Member: * -Select-Addison County SWMDAddison TownAlbany TownAlbany VillageAlburgh Fire District 1Alburgh TownAlburgh VillageAndover TownArlington TownAscutney Fire District 2Athens TownBakersfield Fire District 1Bakersfield TownBaltimore TownBarnard TownBarnet Fire District 2Barnet TownBarre CityBarre TownBarton TownBarton VillageBellows Falls VillageBelvidere TownBennington County Regional CommissionBennington TownBenson TownBerkshire TownBerlin TownBethel TownBloomfield TownBolton TownBradford TownBraintree TownBrandon Fire District 1Brandon Fire District 2Brandon TownBrattleboro TownBridgewater TownBridport TownBrighton TownBristol TownBrookfield TownBrookline TownBrownington TownBrunswick TownBurke Fire District 1Burke TownCabot TownCalais TownCambridge TownCanaan TownCastleton Fire District 1Castleton Fire District 3Castleton TownCavendish Fire District 1Cavendish Fire District 2Cavendish TownCentral Vermont PSACentral Vermont SWMDCharleston TownCharlotte TownChelsea TownChester TownChittenden County PSAChittenden SWDChittenden TownClarendon TownColchester Fire District 1Colchester Fire District 2Colchester TownCold Brook Fire District 1Concord TownCorinth TownCornwall TownCoventry Fire District 1Coventry TownCraftsbury TownDanby TownDanby-Mt Tabor Fire District 1Danville TownDanville Fire District 1Derby Center VillageDerby Line VillageDerby TownDorset TownDover TownDummerston TownDuxbury TownEast Berkshire Fire District 1East Calais Fire District 1East Haven TownEast Middlebury Fire District 1East Montpelier TownEden TownEdward Farrar Utility DistrictElmore TownEnosburgh TownEssex Junction VillageEssex TownFair Haven TownFairfax TownFairfield Fire District 1Fairlee TownFayston TownFerrisburgh Fire District 1Ferrisburgh TownFletcher TownFranklin NRCDFranklin TownGeorgia TownGlover TownGrafton TownGranby TownGrand Isle Consolidated Water DistrictGrand Isle Fire District 4Grand Isle TownGraniteville Fire District 4Granville TownGreater Upper Valley SWMDGreensboro TownGroton TownGuildhall TownGuilford TownH2O FFD 2 (Fairfield 2)Halifax TownHancock TownHardwick Electric DeptHardwick TownHartford TownHartland TownHighgate TownHinesburg TownHolland TownHubbardton TownHuntington Fire District 1Huntington TownHyde Park TownHyde Park VillageIra TownIrasburg Fire District 1Irasburg TownIsle La Motte TownJacksonville VillageJamaica TownJay TownJeffersonville VillageJericho Fire District 1Jericho TownJericho VillageJericho-Underhill Library DistrictJericho-Underhill Park DistrictJericho-Underhill Water DistrictJohnson TownJohnson VillageKillington TownKirby TownLake Iroquois Rec DistrictLamoille County NRCDLamoille Regional SWMDLeicester TownLemington TownLincoln TownLondonderry TownLowell TownLudlow TownLudlow VillageLunenburg Fire District 1Lunenburg Fire District 2Lunenburg TownLyndon TownLyndonville VillageMad River Valley Planning DistrictMaidstone TownManchester TownManchester VillageMarlboro TownMarshfield TownMarshfield VillageMendon TownMiddlebury TownMiddlesex TownMiddletown Springs TownMilton TownMonkton TownMontgomery TownMontpelier CityMoretown TownMorgan TownMorristown TownMorrisville Water and Light DeptMount Ascutney Regional CommissionMount Holly TownMount Tabor TownNew Haven TownNewark TownNewbury TownNewfane TownNewport CityNewport TownNorth Bennington VillageNorth Hero TownNorth Troy VillageNortheast Kingdom WMDNorthfield TownNorthwest Vermont SWMDNorton TownNorwich Fire District 1Norwich TownOld Bennington VillageOrange TownOrleans County NRCDOrwell TownOttauquechee NRCDOtter Creek NRCDPanton TownPawlet TownPeacham Fire District 1Peacham TownPeru TownPittsfield TownPittsford TownPlainfield TownPlymouth TownPomfret TownPoultney TownPoultney VillagePownal Fire District 2Pownal TownProctor TownPutney TownRandolph Fire District 1Randolph TownReading TownReadsboro TownRichford TownRichmond TownRipton TownRochester TownRockingham TownRoxbury TownRoyalton Fire District 1Royalton TownRupert TownRutland CityRutland County SWDRutland TownRutland Town Fire District 1Ryegate Fire District 2Ryegate TownSalisbury TownSandgate TownSaxtons River VillageSearsburg TownShaftsbury TownSharon TownSheffield TownShelburne TownSherburne Fire District 1Sheldon TownShoreham TownShrewsbury TownSolid Waste Alliance CommunitiesSouth Alburgh Fire District 2South Burlington Fire District 1South Burlington Fire District 2South Georgia Fire District 1South Hero Fire District 4South Hero TownSouthern Windsor-Windham County SWMDSpringfield TownSt. Albans CitySt. Albans TownSt. George TownSt. Johnsbury TownStamford TownStannard TownStarksboro TownStockbridge TownStowe Fire District 1Stowe TownStrafford TownStratton TownSudbury TownSunderland TownSutton TownSwanton TownSwanton VillageThetford TownTinmouth TownTopsham TownTownshend TownTri-Town CommissionTroy TownTunbridge TownUnderhill TownUnified Towns and Gores of Essex CountyVergennes CityVergennes-Panton Water DistrictVernon TownVershire TownVictory TownWaitsfield TownWalden TownWallingford Fire District 1Wallingford Fire District 2Wallingford TownWaltham TownWardsboro TownWarren TownWashington Fire District 1Washington TownWaterbury TownWaterford TownWaterville TownWeathersfield TownWebsterville Fire District 3Wells River VillageWells TownWest Fairlee TownWest Haven TownWest Rutland TownWest Windsor TownWestfield Fire District 1Westfield TownWestford TownWestminster Fire District 5Westminster TownWestmore TownWeston TownWeybridge TownWheelock TownWhite River NRCDWhiting TownWhitingham TownWilliamstown TownWilliston TownWilmington TownWilmington Water DistrictWindham County NRCDWindham SWMDWindham TownWindsor TownWinhall TownWinhall-Stratton Fire DistrictWinooski CityWinooski NRCDWinooski Valley Park DistrictWolcott TownWoodbury TownWoodford TownWoodstock TownWoodstock VillageWorcester Fire District 1Worcester TownWrightsville Beach Rec District Other Member Contact's Full Name: * Member Contact's Position/ Title: * Member Contact's Email Address: * Member Contact's Phone Number: * Member Contact's Fax Number: PROPERTY CHANGE OPTIONS Type of Property Change: * -Select-AddDeleteCorrection/ Change Please Describe Details of Corrections/Changes in Comments or Details Section Below Property Address: * Effective or Termination Date? -Select-Effective DateTermination Date Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20202021202220232024 PROPERTY INFORMATION Description of Building: * Building Use: * Department: Is Building Vacant? Yes No Sprinklered? Yes No Construction Type: -Select-FrameJoisted MasonryNon-Combustible Building Value($): Building Replacement Value($): Contents Value ($): Contents Replacement Value($): Number of Employees in Building: Number of Vehicles Garaged: Property Inspection Contact Information: Comments or Details: * Would you like to upload a supporting document? (e.g. detailed property description) Files must be less than 2 MB.Allowed file types: gif jpg jpeg png txt pdf doc docx odt ppt pptx xls xlsx. Add a Second Property? Yes No Fill Out The Information Below To Add a Second Property Change Type of Property Change: * -Select-AddDeleteCorrection/ Change Please Describe Details of Corrections/Changes in Comments or Details Section Below Effective or Termination Date? -Select-Effective DateTermination Date Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2019202020212022202320242025 Description of Building: * Building Use: * Department: Is This Building Vacant? Yes No Sprinklered? Yes No Construction Type: -Select-FrameJoisted MasonryNon-Combustible Building Value ($): Building Replacement Value ($): Contents Value ($): Contents Replacement Value($): Number of Employees in Building: Number of Vehicles Garaged: Property Inspection Contact Information: Leave this field blank
