Fillable UTILITY SERVICE APPLICATION (City of Round Rock, Texas)

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UTILITY SERVICE APPLICATION (City of Round Rock, Texas)

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City of Round Rock

221 E. Main Street

Round Rock, TX 78664

Phone: 512-218-5460

Fax: 512-218-5463

UTILITY SERVICE APPLICATION

START DATE or DISCONNECT DATE

Please allow 1-2 business days for processing. Service will be activated between 8 a.m. and 5 p.m., Monday through Friday. Applications received

on Saturday, Sunday, or holidays will be initiated on the preceding business day.

SERVICE ADDRESS

MAILING ADDRESS

(If different from above)

EMAIL ADDRESS

BILLING PREFERENCE E-BILL or PAPER BILL

APPLICANT CO-APPLICANT

DRIVERS LICENSE # DRIVERS LICENSE #

SOCIAL SECURITY # SOCIAL SECURITY #

BIRTHDAY

PHONE # PHONE #

COMPLETE THIS SECTION FOR NON-RESIDENTIAL UTILITY SERVICE (Commercial, Industrial, Business, Real Estate, etc.)

APPLICANT CONTACT NAME

TAX ID # PHONE #

MONTHLY FRIENDLY ROCK DONATIONS

(I/we agree to make a voluntary monthly donation in the following amount): $1 $

Applicant Co-Applicant

I understand that the City requires 1 – 2 business days’ notice to connect service.

I request that my personal information be kept confidential.

I understand that a $25 connection fee and $100 deposit will be charged on the first month’s bill for residential

accounts. Deposits on commercial accounts will vary according to meter size.

I understand that I am responsible for all discharges of water on the customer side of the water meter, regardless if the

discharge was a result of my actions or inactions.

I understand that I am liable for any damage to the water meter installed on the property. It is unlawful for anyone to

break, damage, tamper with, obstruct or prevent the proper operation of the water meter.

I understand that a violation of any of the offenses listed above will result in additional fees for water lost, damages

incurred, and criminal charges may be filed against the customer.

I am over 60 years old and will bring proof to the city offices within three business days to qualify for a penalty delay. I

understand that until I submit proof and complete the form in office, I will not be granted the payment delay.

I agree both the applicant and co-applicant, if any, have the authority to close the account and that the return of the

deposit, if any, may be issued to either the applicant or the co-applicant.

SIGNATURE CO-APPLICANT SIGNATURE

Submit the completed form along with a copy of your photo ID to the Utility Billing office using any of the following methods:

Online at roundrocktexas.gov/newutilityservice - Fax: 512-218-5463 -

In-person at address listed above

************************************************* OFFICE USE *************************************************

ACCT # CSR SERVICE ORDER # VERIFIED /

UpdatedDecember2016

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UpdatedDecember2016

CityofRoundRock

221E.MainStreet

RoundRock,TX78664

Phone:512‐218‐5460

Fax:512‐218‐5463

AUTOMATICDRAFTAUTHORIZATION

TOENROLLORCHANGEAUTODRAFTONUTILITYACCOUNTS

UTILITYACCOUNTINFORMATION

NAME ACCOUNT#

SERVICEADD

RESS PHONE#

MAILINGADDRESS SOCIALSECURITY#

(Ifdifferentfromabove)

EMAILADDRESS REQUESTE‐BILL YES NO

YoucanhelpthoseinneedpayforessentialwaterservicesbydonatingtotheFRIENDLYROCKPROGRAM.Simplychecktheboxby

theamountyouwouldliketocontributeanditwillbeaddedtoyourwaterbill.

YESIwouldliketopledgetotheFRIENDLYROCKPROGRAMeachmonth.

 $1 $5 $________

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

OPTION1:AUTOMATICDRAFTFROMVISAORMASTERCARD

Completethissectionifdraftingfromcreditcard

CARDTYPE: VISA MASTERCARD

CARDNUMBER ‐‐ ‐ EXPIRATION

CARDHOLDERNAME BILLINGZIPCODE

CVV(3DIGITNUMBERONBACKOFCARD)

OPTION2:AUTOMATICDRAFTFROMBANKACCOUNT

Completethissectionifdraftingfromcheckingorsavingsaccount.

***Avoidedcheckisrequiredfordraftsfromcheckingorsavingsaccounts***

CHECKING SAVINGS

BANKNAME BANKACCOUNT#

NAMEONBANKACCOUNT BANKROUTING#

IauthorizetheCityofRoundRocktodrafttheaccountindicatedabovetopaymymonthlyutilitybill.Iunderstandthatmycredit

cardorbankaccountmaybedraftedforthetotalamountdue,onetothreebusinessdaysbeforetheduedate.Initial

Iwillcontinuetomakepaymentsasusualuntilmybillstates“PaidbyDraft”.Failuretodosomayresultinlatefees.Initial

ThisauthorizationwillremainineffectuntiltheCityofRoundRockhasreceivedwrittennotificationoftermination.Thisbankor

creditcarddraftauthorizationwillbeterminateduponreceiptofnotificationforinsufficientfundsorifdeclinedorreturnedforany

reason.Initial

SIGNATURE DATE

*************************************************OFFICEUSE*************************************************

ENTEREDBY DATE VERIFIEDBY DATE

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CityofRoundRock

UtilityBillingCustomerSurvey

Wewanttoprovideourcustomerswiththebestcustomerserviceavailable.Commentsfrom

youwillhelpusreachthatgoal.Pleasetakeafewmomentsto

filloutthissurveyandsendit

backtous.Youcanreachusbyphoneat512-218‐5460orfaxat512‐218‐5463.

Wereyoutreatedinafriendlyandwelcomingmanner? Yes No

Wasthecustomerservicerepresentativeknowledgeableandhelpful? Yes No

Didwerespondprofessionallyandanswerallyourquestions? Yes No

4(excellent)

HowdoyourateyouroverallexperiencewiththeUtilityBillingOffice?

Yes No

Maywecontactyouaboutthissurvey:

IfYes: Name _______________________________________________

Address _____________________________________________

PhoneNumber_______________________________________

IrmaMendoza

CityofRoundRock

221EastMainStreet

RoundRock,TX78664

512‐218‐5460

1(poor) 2(average)  3(good)

Comments:

UpdatedDecember2016

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Completed 4 August 2020

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