TOWN OF CULPEPER, VIRGINIA
400 South Main Street, Suite 109
Culpeper, VA 22701
Phone: (540) 829-8220 FAX: (540) 829-8239
Primary Customer Name
Service Address
Mailing Address
Soc. Sec #/F.I.N. #
Telephone
Email
Employer Name
Employer Address
Last: ______________________ First: ____________________ Middle Initial: ______
: ____________________________________________________________________________
: ____________________________________________________________________________
: _______ - _______ - _______ Date of Birth: _____ / ______ / ______
: Home: (____) _____ - _____ Work: (____) _____ - _____ cell: (____) _____ - _____:
: ____________________________________________________________________________
_____________________________________________________________________________
: ____________________________________________________________________________
Secondary Customer Name
Soc. Sec #/F.I.N. #
Employer Name
Employer Address
Work Telephone
Last: ______________________ First: ____________________ Middle Initial: ______
: _______ - _______ - _______ Date of Birth: _____ / ______ / ______
: ____________________________________________________________________________
: ____________________________________________________________________________
: (____) _____- ____ cell: (____) _____- ____ email: _____________________________
: ____________________________________________________________________________
: ____________________________________________________________________________
: _______ - _______ - _______ email: _______________________________________
Not living with you
EMERGENCY CONTACT
Contact Address
Contact Phone #
Have you had service with the Town of Culpeper previously: Yes No
If yes, when & where? ___________________________________________________________________________________________
Date you desire service to be connected: : _______ / _______ /_______
Do you Lease or own? (Attach copy of lease / proof of ownership)
If you Lease: property owner’s name: ____________________________________________________________
property owner’s address: ____________________________________________________________
phone: (_____) _______ - ________ ____________________________________________________________
SERVICE TYPE: Business Residential Do you operate an in-home business? _____
Electric Water Sewer Bulk Septage Water Haul Security Lights
Trash-monthly charge $ __________ Additional trash carts _____ x _____ = _________
*For connections: Electric Breakers and/or Water Valves must be off. There will be add'l. $50 fee for a 2nd trip to connect services.
SUBSCRIBED, ACKNOWLEDGED, AND AFFIRMED BEFORE ME THIS __________ day of ______________________, 20 ______
MY COMMISSION EXPIRES: _____________________________ NOTARY _____________________________________________
PLEASE READ BOTH SIDES OF THIS APPLICATION BEFORE SIGNING BILLING PROCEDURES ARE ON REVERSE SIDE
I have read both sides of this application; understand and agree to adhere to all the Town of Culpeper’s billing procedures; do hereby authorize
requested utility service (s) to be established in my name at the above address; and agree to pay for such service until terminated at my request.
************** OFFICE USE ONLY ************** OFFICE USE ONLY ************* OFFICE USE ONLY **************
_____ / _____/ _____ ___________________________________________________________________________________________
DATE PRIMARY CUSTOMER SIGNATURE (see reverse side)
_____ / _____/ _____ ___________________________________________________________________________________________
DATE SECONDARY CUSTOMER SIGNATURE (see reverse side)
Amount of Deposit: $ __________ Application Fee: $ __________
Customer Number: __________ Date Paid: ________ / _______ / _______
Account Number: __________ Cashier Initials: __________
Trash Can Number: __________
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UTILITY BILLING PROCEDURES
All fees and procedures are subject to change as established and set by the Town Council. It is a condition of the
agreement between the Town and the applicant for utility services that the Town shall not be considered a guarantor with
respect either to the continued or uninterrupted supply of such services contemplated in this application.
All Social Security numbers provided herein will be used for the sole purpose of complying with the State of Virginia's Set-
Off Debt Collection Act (section 58.1-520 et seq) The Town of Culpeper's authority to request Social Security numbers as
part of the Town's Utility Application derives from Code of Virginia section 58.1-521, Code of Virginia section 2.2-3808
(A)(2)(i)(ii) and the Federal Privacy Act of 1974 section 7(b). The disclosure of your Social Security number as part of the
Utility Application process is voluntary. No applicant for utility services will be denied the provision of utilities because of
their refusal to disclose his/her Social Security number. If the applicant does not provide a Social Security number, two (2)
other forms of government identification will be required. Acceptable forms of government identification include:
Green card
Passport
T-number (number/card issued by the IRS so that they can pay taxes)
Valid state issued drivers license
Valid state issued identification card if you do not receive your bill by the third working day after the billing date,
there may be an error in postal delivery, and you should contact the Treasurer's Office to receive a duplicate and/or find out
the amount of your bill so it can be paid by the due date. If you do not pay your bill by the due date, a penalty of $1.50 or
two percent (2%) of the billed amount, whichever is greater, will immediately be due and payable on your bill. If a bill is not
paid in full 10 days after the due date, a delinquent charge ($15 for one utility or $20 for two utilities) shall be added to the
account and services will be DISCONNECTED WITHOUT FURTHER NOTICE. Once a service notice to disconnect HAS
BEEN PROCESSED, a reconnection fee of $25 and $25 additional deposit shall be charged to the account. PRIOR TO
RECONNECTION ALL FEES OWED MUST BE PAID TO THE TREASURER'S OFFICE. An afterhour’s fee shall apply to
reconnection of disconnected services for non-payment after normal business hours. A $35 fee will be charged on all
returned checks. If a deposit for services has been made, the customer consents to the application of such deposit by the
Town Treasurer, or as much thereof as may be necessary, to the payment of any proper bill owed for such services
remaining unpaid. If a balance is owed upon final termination of utility services and it is not paid within one month of
rendering the bill, the customer agrees to pay the delinquent bill, all applicable service charges (a service charge of .0083
per month will be added to the unpaid balance on account 30 days and over -10 percent per annum), and reasonable
attorney's and/or collection fees necessary to collect said bill. A customer may request in writing, that his deposit be
refunded once he has established good credit by paying his bill by the due date at the same location for a period of two (2)
years for residential and five (5) years for commercial customers.
In the event a customer moves, it is his responsibility to make arrangements with the Town to get a final meter reading.
The bill generated from this final reading will be marked FINAL BILL. The final bill will be deducted from the deposit (if any),
and the balance of the deposit will be refunded to the customer or he will be notified at the last known address if a balance
is due on the account. If a customer leaves one place of service and moves to another Town service area and fails to pay
the remaining billed amount on the former service plus all applicable penalties, delinquent charges, and fees by the
delinquent date, then the new service is subject to immediate disconnection. Payments may be mailed to the
TREASURER'S OFFICE, placed in the night depository, which is provided for convenience outside the Municipal Building at
400 South Main Street, or most local banks offer the convenience of being able to pay utility bills on or before the due date.
Partial or late payments will not be accepted by the banks. When choosing a method of payment, remember payments will
not be credited to the account until they are received by the Treasurer's Office, and the Town will not be held responsible
for cash payments without proper receipt documentation. IT IS UNLAWFUL FOR ANY PERSON TO REMOVE, TAMPER
WITH, OR DAMAGE ANY METER, POLE, TRANSFORMER OR OTHER APPARATUS OR EQUIPMENT BELONGING
TO OR USED BY THE TOWN IN CONNECTION WITH ITS UTILITY SYSTEMS AS DEFINED IN THE TOWN CODE AND
THE CODE OF VIRGINIA. If you have problems with your electrical service, first check all fuses and/or circuit breakers. If
you have any problems with your water service, please check with a neighbor to see if they have the same problem. If you
cannot locate the problem, you should contact the Utility Billing Department at 540.829.8220 weekdays from 8 a.m. to 5
p.m. For billing related questions, please contact the Treasurer's office at 540.829.8220 weekdays from 8 a.m. to 5 p.m.