Dutchess County, NY · Dutchess County
Public Notification Certification Form
Public water systems use this form to certify that they notified consumers about a violation or situation and distributed the required public notice.
At a glance
- Issued by
- City of Dutchess County · Dutchess County, Dutchess County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- dutchessny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form records a public water system’s violation or situation, notification tier, consultation, and methods and dates used to distribute public notice. The form and a copy of each completed public notice must be submitted to the State within 10 days of notifying customers. It collects water system details, certification statements, and signatures and contact information for the owner or executive director and operator.
Who needs it
The owner or executive director and operator of a public water system complete this form after providing public notice to consumers.
How to submit it
Submit this form with a copy of the completed public notice to the State within 10 days of notifying customers; the document does not specify a submission method.
About notarization
This document is signed without a notary; the owner or executive director and operator sign and date the certification.
How to submit this form
- 1
Download the Form
Download the Public Notification Certification Form.
- 2
Complete the Form
Enter the water system information, violation or situation details, notification tier, and notice distribution methods and dates.
- 3
Attach the Public Notice
Attach a copy of each completed public notice to the certification form.
- 4
Sign and Submit
Have the owner or executive director and operator sign and date the form, then submit it with the notice to the State within 10 days of notifying customers.
Frequently asked questions
- What is the Public Notification Certification Form for?
- It certifies that a public water system provided consumer notification and records the violation or situation, notification tier, and notice distribution methods and dates.
- Who completes this form?
- The form is for the public water system owner or executive director and operator to complete and sign after notifying consumers.
- Do I need a notary for the Public Notification Certification Form?
- No. This document is signed without a notary; the owner or executive director and operator sign and date the certification.
- How do I submit the Public Notification Certification Form?
- Submit the form with a copy of the completed public notice to the State within 10 days of notifying customers. The document does not specify a submission method.