Fillable Stockbridge Munsee Public Works Department Water /Sewer Customer

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Stockbridge Munsee Public Works Department Water /Sewer Customer

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Stockbridge Munsee Public Works Department
Water /Sewer Customer Registration
You are required to attach a copy of the land assignment showing ownership, any application
that does not have the land assignment attached is NOT complete and will not be processed.
Cost is $40.00 to file this paper work and have account put into your name or changed to another
person’s name. ( Chapter 39 Tribal Utility Ordinance)
**Land Owners: Please be aware that you can place the account into a renters name but the
ultimate liability remains with the landowner. Any balances left by someone other than the
owner become the owner’s responsibility which may include late fees, disconnection fees, court
costs etc. New/Change of services will not be processed until all balances are paid in full.
Request for: New User __________ Change to Existing Account __________
Date request is to be effective: ____________________________________________
------------------------------------------------------------------------------------------------------------------
This section must be filled out!!
Land owner Name: _________________________________________________
Land owner current address : _________________________________________
_________________________________________
Land owner phone number: _______________________________
--------------------------------------------------------------------------------------------------------------------
This section for a Change to Existing Account
Name to be placed on service: _______________________________________________
Street Address of Service request: ____________________________________________
Mailing Address (if different from above): _____________________________________
_____________________________________
Phone number for service address: ___________________________________
__________________________________________________
Signature of Land Owner *By signing I agree that any balances left by myself or other party whom I agree to allow
services at my address will ultimately be my responsibility and the Tribe may pursue those balances in my name.
__________________________________________________
Signature of Other party requesting service
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Stockbridge Munsee Public Works Department Water Sewer Customer

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Completed 27 January 2021

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