APPLICATION FOR RESIDENTIAL UTILITY SERVICE
NAME ______________________________________________ SOCIAL SECURITY #_________________
CO-APPLICANT ______________________________________ SOCIAL SECURITY #_________________
SERVICE ADDRESS _______________________________________________________________________
BILLING ADDRESS _______________________________________________________________________
TELEPHONE # ____________________________________________________________________________
IF TRANSFERRING SERVICE WITHIN THE CITY, PLEASE FILL OUT THE FOLLOWING:
DISCONNECTION DATE REQUESTED _______________________________________________________
NAME OF EMPLOYER _________________________________ TELEPHONE # ______________________
CONTACT PERSON (NOT LIVING WITH YOU)
ADDRESS ______________________________________________ TELEPHONE # ____________________
I UNDERSTAND THAT A PENALTYWILL BE ASSESSED ON BILLS NOT PAID BY THE DUE DATE AS SHOWN ON THE BILL AND SERVICE MAY BE DISCONTINUED FOR NON-PAYMENT. THE UNDERSIGNED WILL BE RESPONSIBLE FOR PAYMENT FOR ALL UTILITY CHARGES UNTIL NOTIFICATION IS GIVEN TO DISCONNECT SERVICE. I ALSO DECLARE THAT THE INFORMATION PROVIDED IS TRUE, FULL AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
NOTE: IT IS A MISDEMEANOR FOR ANY PERSON TO WILLFULLY MAKE ANY FALSE STATEMENTS IN ORDER TO RECEIVE UTILITY SERVICE. (CODE OF VIRGINIA SECTION 18.2-186)
OFFICE USE ONLY:
____NEW ACCT ____DEP WVD-GOOD HIST ____ELECTRIC SERVICE ONLY
____TRNSFR ____LETTER OF CREDIT ____WATER SERVICE ONLY
____DEP REQRD ____DEP TRNSFRD TO NEW ACCT ____ELECTRIC, WATER, SEWER, REFUSE
CSR_________ ID VERIFY__________________ ____________________________________________
INFORMATION FOR RESIDENTIAL UTILITY SERVICE
to the City of
In order to establish utility service the following must be provided.
Valid pictured identification (Drivers License, passport)
Customers are asked to provide a sales contract, lease, or move-in slip.
The City of
For joint accounts, both signatures and valid identifications are required.
deposits may be waived with a satisfactory rating return on the credit check.
Security deposits are placed on accounts for a period of one year. If after one year, there are no disconnect notices, no returned checks, and no more than one late charge, the deposit is applied to the account as a credit. Should you request to disconnect your service before one year, the deposit is then applied to your account and any remaining credit will be refunded.
Checks returned will be subject to a $35.00 fee, and utility service may be disconnected without notice.
For new service or transfer of service, there is a non-refundable service charge. This charge can be paid at the time of application or it may be applied to your first utility bill. The service charge for an electric only account is $25.00; for accounts with both electric and water, the service charge is $50.00.
Should disconnection of your utility service occur due to non-payment, a deposit increase, reconnection charge and full payment of the account is required before reconnection of service can occur.
Please ask your Customer Service Representative for refuse and recycling information.
Utilities Services Manager