Please complete this form and return to the officeFull NameDateAddressPenalty AmountReason for WaiverSignatureDateOffice ManagerBoardto Fill in BelowApproved ID: 839867
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1 P.O. Box 205, East Greenville PA 18041
P.O. Box 205, East Greenville PA 18041 679billing@tuha.org Please complete this form and return to the officeFull NameDateAddressPenalty AmountReason for Waiver:SignatureDate:Office ManagerBoardto Fill in BelowApproved: ______________ Amount Approved: $________________Not Approved: ___________Manager Comments:Office Manager or Board Date: THE UPPER HANOVER AUTHORITY PENALTY WAIVER REQUEST FORM