Fillable Form 1: Utility Billing Application (City of Pooler)

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Form 1: Utility Billing Application (City of Pooler)

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U.S.A. forms for City of Pooler

BROWSE CITY OF POOLER (GA) FORMS

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Utility Billing Application
1
Homeowners please submit this application
We accept cash, check, & debit
along with a copy of HUD and photo id.
Applications by mail, fax, or email with required
Renters are required to pay a $150.00 Deposit
documentation, drivers license, and SS card
($75.00 for sanitation only accounts) plus
must be submitted to process application.
submit a copy of lease agreement and photo id.
City of Pooler
100 US HWY 80 SW
A $75 non-refundable sanitation maintenance
Pooler, GA 31322
fee will be billed to all new customers.
Ph. (912) 748-4800
Fax (912)748-6777
utilitybilling@pooler-ga.gov
Apartment/Suite City State Zip
Month Day Year
Place of Employment_____________________________
Work Phone # ( ) -
I would like to receive bill by: (please check)
MAIL
EBILL (email)
Email (Ebill) address ________________________________________
Last First M.I.
___________________________________________ __________________________ ____________________________ _______________________________
Email address ________________________________________
Co-Applicant Name_________________________________________________
Transfer/Previous Address Information
Drivers License _______________________________________
Bill Delivery Options
Drivers License _______________________________________
Month Day Year
Home Phone # ( ) -
Cell Phone # ( ) -
Cell Phone # ( ) -
SSN - -
SSN - -
OFFICE USE ONLY
Applicant/Owner Information
ACCT_________________________________________________________________
SETTLEMENT PAPERS__________________________________________________
DEPOSIT RECEIPT #_____________________________________________________
COPY OF C.O.________________________________________________________
Own __________ Settlement Statement Required
CHECK #____________________________________________________________
Birth date _________/__________/___________
DATE ENTERED _________/__________/___________
BY:_________________________________________________________________
Name________________________________________________________
Birth date _________/__________/___________
Today's Date _________/__________/___________
Rent _________ Requires $150 deposit & copy of lease
Mailing Address (If different from service address)__________________________________________________________________________________
Date to Start Service _________/__________/___________
Service Address_____________________________________________________________________________________________________________
Last First M.I.
"The following information is required by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants
seeking to participate in the program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in
Place of Employment_____________________________
Work Phone # ( ) -
If Yes, Previous Address_______________________________________________________________________________________________________
(If transferring account, please fill out disconnection form)
Have you ever had service with the City of Pooler before? Yes______ No_______
evaluation of your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national
Utility Billing Application
2
X_____________________________________________________
X______________________
Applicant Date
X____________________________________________________
X______________________
Co-Applicant/Spouse Date
Complaints of discrimination may be filed with the Secretary of Agriculture. Washington DC 20250"
origin of individual applicants on the basis of visual observance or surname.
□ White, not of Hispanic origin □ Hispanic □ Black, not of Hispanic origin
□ Asian or Pacific Islander □ American Indian or Alaskan native
"This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law.
eBill is a conveinance for utility customers. Applicants are soley responsible for updating eBill information; eBills not received are the sole responsibility of
applicants.
Payments made after 5pm are posted the following business day. Any penalty or suspension of service due to payments received after 5pm are the sole
responsibility of applicant
The City of Pooler does not require you to be home when service is established. It is your responsibility to ensure that all water faucets are off and there are no
leaks during the cut on procedure. If there is any water running at the time of cut on, the water service will be turned off at the meter and a notice will be left on the
door instructing you to call the Utility Billing Office to schedule connection.
You are responsible for any and all City of Pooler utility bills generated at the address of service until a request of disconnection is received in writing to the
City of Pooler Utility Billing Office. Monthly charges will continue as long as service is furnished in the applicant's name at the service address. Charges for water,
sewer, and sanitation services continue when service is active whether used or not.
Your signature below indicates that you, the applicant, have read and understand the following statements:
All information is correct to the best of your (the applicants) knowledge.
You agree to receive utility service(s) from the City of Pooler in accordance with current and future ordinances, regulations, and rates.
Deposits shall not be returned until service is disconnected and the account balance has been paid in full.
All account changes must be submitted in writing to the City of Pooler's Utility Billing Department at 100 US HWY 80 SW, Pooler, GA 31322.
If service is suspended for nonpayment, you will be required to pay account balance in full plus a $50.00 penalty fee to have service
restored.
A $75.00 non-refundable sanitation maintenance fee may be reflected on your first utility bill.
A 10% late penalty will be applied to your account if the balance is not paid by the due date.
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Form 1: Utility Billing Application (City of Pooler)

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Completed 4 August 2020

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