Elyria City Hall
131 Court Street ,Suite 102
Elyria, Ohio 44035
Phone: (440) 326-1570 Fax: (440)-326-1588
SERVICE ADDRESS:________________________________________________________________________________________
(Street Address) (City, State and Zip code)
ACCOUNT HOLDER/APPLICANT (NAME):___________________________________________________________________
(Last, First, MI OR Business Name)
Please select one of the following: OWNER TENANT MANAGEMENT COMPANY REALTOR
Telephone Number(____)______________________Cell Phone Number(___)__________________________________
Email Address:__________________________ Driver License/ ID Number: ___________________________________
Have you had a previous account with City of Elyria different than the service address?
(If different than Service Address Above)
If TENANT, provide the following owner information:
Owner / Landlord Name:___________________________________________________________________________________
Telephone Number (____)________________________________
Cell Phone Number (___)__________________________
Additional After Hours Emergency Number:(if available)(____)___________________________________________________
Email Address:____________________________________________________________________________________________
(Please Initial) ____
In consideration for receiving utility service from The City of Elyria at the above location, I hereby acknowledge responsibility for
payment of service billings. All utility accounts are billed and payment by the indicated due date is required to prevent interruption of
service. I am responsible for utility service until your account is closed.
I understand that The City of Elyria is not responsible for water damage to this property or its contents. In consideration for having
utility service initiated/ restored at the above address, I agree to ensure that all water service facilities (sink and tub faucet/ inside and
outside, toilets, etc.) are turned off: or that the responsible account holder or designee will be present to check for leakage.
We recommend that you turn off your private shut off valve, if applicable. Once the application is processed, it may take up to 5
business days to restore service.
Account Holder/ Applicant Signature: ______________________________________ Date: __________________________________________
Security Deposit Information:
This deposit shall constitute a guarantee that all sums due the City for furnishing utility service are fully paid. The City shall upon permanent
disconnection of water services, refund any deposit remaining after deducting all amounts due the City for such services. Furthermore, the deposit
shall not preclude the City from discontinuing for non-payment any and all services regardless of the sufficiency of the deposit to cover such
Please note: All utility service will remain active and is the responsibility of the property owner even during lapses in occupancy with any
rental property. Charges will be billed to the property owner. For a listing of complete EPU rules see Chapter 939 of Codified Ordinance or
_____________________________________________________________________ Date: _______________________
Account Holder/ Applicant Signature
Owner/Landlord/Agent Signature
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