Application Date __________ Service Start Date ___________
Customer or Business Name ________________________________________________________________
Service Address __________________________________________________________________________
Mailing Address __________________________________________________________________________
Home Phone ____________________ Cell Phone ____________________ Work Phone ________________
Name & Address of Employer _______________________________________________________________
D.L. State & Number:___________________________________ S.S. # _____________________________
Date of Birth: ____ / ____ / ____ AGE ______ MARITAL STATUS: __________ SEX: _____ F _____M
Spouses Full Name _____________________________________ Maiden Name ______________________
Email Address _________________________ Alternate Contact Info _______________________________
Have you had service with us before? ___ YES ___ NO Do you own or rent this property? ___O ___ R
Name & Number of Landlord ________________________________________________________________
The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination
against applicants in the program. You are not required to furnish this information, but are encouraged to do so. This information will not be
used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note
race/national origin of individual applicants on the best visual observation or surname.
_____ White, Not of Hispanic Origin _____ Hispanic _____ Black, Not of Hispanic Origin
_____ Asian or Pacific Islander _____ American Indian or Alaskan Native _____ Other
I certify the information provided in this application is true and correct. I understand that I am responsible for all charges incurred as of the
service connection date. I have read and understand the instructions and information page of this application. I have also received a copy of
this page which is titled “Instructions and Information about Your Account”. I am ready for services to be turned on and I assume all risk of
water damage to my property in the event any of my faucets are open when water service is turned on.
Applicant Signature _______________________________________________________ Date ___________________
===================================OFFICE USE ONLY======================================
ACCOUNT NUMBER: _____________________________________ READING: ________________________
RATE CODE/SERVICES ___________________________________ SENIOR CITIZEN? YES ______ NO ______
CHARGES: DEPOSIT __________ + NEW SERVICE __________ + OTHER ___________ = TOTAL ___________
AMOUNT PAID $_________ DATE PAID _________BY ________________________ CHECK ____ CASH ____
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Your Weekly Household Garbage Pickup Day ________________ Call City Hall for Yard Trash Pickup 912-496-2563
Applicants are required to complete and return this form in person to City Hall prior to any utility services
being activated. Applicants will also need to provide their social security number and a valid Driver’s License
or acceptable picture I.D.
Renters are required to have the landlord complete the rental section prior to connection.
A deposit of $125.00 is required on all accounts. The amount must be paid in full before services can be
established. The deposit will be returned to the applicant in the form of a check when the service is
Any unpaid balances from previous accounts must be paid in full prior to connection.
City Hall is located at 541 First Street in Folkston, Georgia. Our hours of operation are 8:00am to 5:00pm
Monday, Tuesday, Wednesday & Friday and from 8:00am to 3:00pm on Thursday excluding holidays.
All utility bills are due on the 15
of every month, excluding weekends & holidays. If the 15
is on a weekend
or holiday, bills will be due on the next business day. Failure to receive a bill does not relieve you of your
obligation to pay the bill by the due date.
Please include your account number or payment stub from your utility bill when making a payment to ensure
proper credit is applied to your account.
A 10% late fee will be added to all accounts not paid in full on the specified due date. All accounts that are 30
days past due will be disconnected for non-payment without further notice. A reconnection fee of $50.00
plus the past due amount will be due to restore service.
Written authorization on a disconnect form is required to close an account. Minimum bills will continue until
a completed disconnect form is received by our office.
A fee of $35.00 will be charged for any check or automated debit returned for insufficient funds, stop
payment or issued on a closed account.
One 90 gal. roll out garbage container is provided for your residence. Businesses must contract with a private
company for dumpster services.
The fee for household garbage pickup is $10.00 per container each month and is billed on your water/sewer
The fee for yard debris and misc. trash pickup is $5.00 each month and is billed on your water/sewer bill.
Land clearing and construction/building debris will not be picked up by the City. It will be the
contractor/owners responsibility to have these items removed.
Yard debris/misc. trash should be placed behind the curb, not on the streets and should not be underneath
any overhead obstruction such as power lines, phone lines or trees.
Excessive amounts of yard debris/misc. trash will be charged a fee of $25.00 per load.
If you need assistance with where your items should be placed or need special pickup, please call City Hall at
BY MAIL - Mail a check or money order to our address using the envelope included with your bill.
IN PERSON AT CITY HALL Our payment counter accepts checks, money orders or cash.
PAYMENT DROP BOX Located at front door of City Hall.
AUTOMATIC BANK DRAFT Set this up by completing a bank draft authorization & attaching a voided check.