Fillable SERVICE APPLICATION FOR WATER, ELECTRIC AND/OR SEWAGE (City of Proctor)

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SERVICE APPLICATION FOR WATER, ELECTRIC AND/OR SEWAGE (City of Proctor)

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SERVICE APPLICATION FOR WATER, ELECTRIC AND/OR SEWAGE
1
PUBLIC UTILITIES COMMISSION/CITY OF PROCTOR (PUC)
100 PIONK DRIVE
PROCTOR, MINNESOTA 55810
PHONE: (218) 624-4055 / WWW.PROCTORMN.GOV
EFF
ECTIVE DATE___________________________ ACCOUNT NUMBER______________________
APPLICANT TYPE
TYPE OF SERVICE
INDIVIDUAL
COMMERCIAL
RESIDENTIAL-FEE OWNER OR DEED HOLDER
RESIDENTIAL- RENTAL (DEPOSIT REQUIRED)
RESIDENTIAL- CONTRACT FOR DEED OR ASSIGNMENT OF CONTRACT
(DEPOSIT
REQUIRED)
COMMERCIAL-FEE OWNER OR DEED HOLDER
COMMERCIAL- RENTAL
(DEPOSIT REQUIRED)
COMMERCIAL- CONTRACT FOR DEED OR ASSIGNMENT OF CONTRACT(DEPOSIT
REQUIRED)
OWNER/TENANT
LAST NAME FIRST NAME MIDDLE INITIAL
PROPERTY ADDRESS
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
HOME/CELL PHONE NUMBER:
ADDITIONAL NAME ON ACCOUNT AND PHONE NUMBER:
EMAIL ADDRESS:
PRIMARY HEAT IS ELECTRIC YES NO
EMPLOYER NAME:
EMPLOYER ADDRESS:
TENANTS/OWNER OF PREMISES ONLY
LANDLORD NAME:
LANDLORD PHONE NUMBER:
NUMBER OF ROOMMATES:
NAME OF ROOMMATE:
AMOUNT OF DEPOSIT:
DEPOSIT DATE:
SECURITY DEPOSIT:
The Applicant, by signing below, agrees and understands that:
A deposit of a 3 month average will be required for all rentals/contract for deed properties. The total deposit
amount must be submitted with this Application. The deposit, including interest, will be returned after 2 years of prompt
payments and/or cancel of utility service.
If an applicant cancels the utility service within the 2 years, the deposit, including interest, is credited towards
the final utility bill, and any surplus with be refunded to the Applicant.
If at any time, Applicant’s utility is disconnected for non-payment, an additional deposit maybe required prior to
reconnection of the service.
Ag
reed this _____________ day of __________________________________, 20_________________
Ap
plicant Signature ___________________________________________________________________
SERVICE APPLICATION FOR WATER, ELECTRIC AND/OR SEWAGE
2
COMMERCIAL OR INDUSTRIAL CUSTOMERS:
CORPORATION OR LLC:
FEDERAL TAX ID NUMBER:
PROPERTY ADDRESS
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
OFFICERS NAME:
TITLE:
PHONE NUMBER:
Applicant agrees to pay all valid bills or charges for all Utility Service, including for damage to any meters, and Applicant hereby
authorizes the shutting off all Utility Services for any failure of payment.
Applicant further agrees that payment for all Utility Services shall be the primary responsibility for the owner of the property
served by the Proctor Public Utilities and that any and or all unpaid amounts for Utility Service shall be a lien on the property upon sale of
property.
In the case of rental property, the tenant and owner hereby grant permission for the PUC to release Utility Services account
information, including, but not limited to, duplicate copies of bills for any Utility Services account to the owner and/or tenant.
Applicant also herby agrees PUC has the right to access to any meters at all reasonable hours for readings and/or examination of
the meters.
By signing this application, the applicant agrees that the water meter inside the building is always considered to be the correct
reading (unless determined by PUC otherwise), and not that of the water remote attached to the outside of the building. If there is any
discrepancy between the remote reading and the water meter reading PUC will, based on its findings, schedule the necessary repairs and
either bill the applicant for the additional consumption or credit the applicant’s account for the overestimate; therefore, it is in the
applicant’s best interest to periodically compare the two readings and promptly notify PUC of any discrepancies. (If applicable)
Agreed this _____________ day of ____________________________________, 20_________________
Applicant Signature ____________________________________________________________________
Office Use Only
ID TYPE_____________________________________ ID #______________________________________________
DOB___________________
PREVIOUS CUSTOMER OF PROCTOR PUBLIC UTILITIES YES NO IF YES,
ADDRESS________________________________________
SERVICE WAS IN THE NAME OF _________________________________________________ DATE
DISCONNECTED_______________________
ACKNOWLEDGMENT OF RESPONSIBILITY:
In the event the tenant/contract vendee fails to pay any billing hereunder, the PUC and/or City of Proctor shall
bill the landlord/ fee owner the remainder prior to resumption of service.
Landlord/ Fee Owner Signature ________________________________Date________________________________
SERVICE APPLICATION FOR WATER, ELECTRIC AND/OR SEWAGE
3
LIEN AGREEMENT
Pursuant to Proctor City Code §403, et seq., the undersigned fee owner of the real property being provided Utility Service as set forth in
the above application, does hereby agree that, in lieu of paying the required deposit set forth above, the undersigned owner agrees to
allow all unpaid utility charges incurred through use or occupation of the real property in question to constitute a lien against the real
property, legally described as:
(Insert legal description from tax statement.)
With an address of _____________________________________________________________________________.
Said lien shall be in the name of the City of Proctor in the case of sewer and in the name of the Proctor Public
Utility Commission in the case of water and electric.
Agreed this _____________ day of ____________________________________, 20_________________
FEE OWNER SIGNATURE:
CITY OF PROCTOR SIGNATURE:
TENANT OR CONTRACT VENDEE SIGNATURE:
PUBLIC UTILITIES COMMISSION SIGNATURE: (if applicable)
STATE OF MINNESOTA )
) ss
COUNTY OF ST. LOUIS )
On this _______________ day of ________________________________________________, 20___________,
Before me a notary public within and for said County and State, personally appeared
______________________________________________________, to me known to be the same person(s)
described in and who executed the foregoing instrument, and acknowledged that he/she/they executed the
same as his/her/their free act and deed.
____________________________________________
Notary Public
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SERVICE APPLICATION FOR WATER, ELECTRIC ANDOR SEWAGE (City of Proctor)

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Completed 9 February 2021

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