Application for Water/Sewer/Garbage Service

Today’s Date:  _______________                                                    Account Number:  ______________

Effective as of:  _______________

Name:  _________________________________________________

Verification:  Social Security Number:  __________________________

                   Drivers License # or ID #:  __________________________

                   (Attach copy of a photo ID to back.)

Moving to:           Address:   _____________________________________________

                             City:  ____________________________            State:  __________

                             Phone:  _______________________________

                             Garbage:      YES            NO

                             Is this property a rental?  YES            NO

                             If Rental please fill out below:

                                      Owner’s Name:  __________________________________

                                     Address:______________________________   

                                    City/State/Zip Code:  ________________________________

                                     Phone #:  __________________________________

Moving from:       Address:   ____________________________________________

                             City:  ________________________________    State:  _________

                             Phone:  _______________________________

                             Forwarding Address:   ____________________________________

                                      City/State/Zip:  ______________________________________

                                      Phone #:  __________________________________________

I, the undersigned, do understand and agree that:

1.)        All utility bills are due and payable by the 8^th of the month billed.

2.)        Non-payment of bills when due will result in discontinuance of service.

3.)        That in the case where I am purchasing a property, past due unpaid bills created by the prior occupants must be paid in full before utilities will be transferred, and that certain charges, if not paid can and will be certified to the Allen County Auditor for addition to the property taxes.

4.)        The use of these services shall conform to the Rules and Regulation of the Village of Spencerville Utility Department.  Upon signing this document the service applicant agrees to the indicated conditions regarding the provisions of the service.

_____________________________________________

Applicant’s Signature                                        Date

__________________________________________________________________________________

Spencerville Water Dept. Use Only:

New Account Number:  _____________________________________ OK BY:  ________________

Faxed to:  ________________________________________            Date:  ____________________

Time:  ___________________  AM / PM                   BY:  ________________________________

Village Council/Mayor * Street Department * Water Department  *  Waste Water Department *  Police Department * Swimming Pool * Income Tax Department  Other Community Links * Scenes From Around Town * How to Contact Us * Forms * Property Maintenance Codes * Home