Fill - Free fillable Utilities Residential Application

400 S. Main St., Suite 109 Cul

er, VA 22701

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CUSTOMER NUMBER

LOCATION NUMBER

TRASH CART

AMOUNT PAID

DATE PAID

INITIALS

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Residential Account Application

Town of Culpeper

Customer Service: 540-829-8220

Fax: 540-829-8239

Email: payonline@culpeperva.gov

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FICIAL USE ONLY

Customer Information

Residential Renter Residential Owner

(Deposit required. Electric-$250/Water-$50)

Type of service:

Check all that apply Electric Water/Sewer Trash

Utility Service

ddress:

Mailing Address (if different):

1. Primary Customer Name (Last, First, Middle)

SSN: Date of Birth: Email:

Employer Name & Address:

Daytime phone: Evening phone:

2. Secondary Customer Name (Last, First, Middle)

SSN: Date of Birth: Email:

Employer Name & Address:

Daytime phone: Evening phone:

Emergency Contact(Not living with you)

Name:

Emergency contact phone #:

If Renting, Owner Information:

Owner Name:

Address:

Daytime phone number:

Have you had service before with the Town of Culpeper?

Yes No

If yes, when & where?

Date desired service to be connected:

Primary customer signature: Date:

Secondary customer signature: Date:

lication Fee: $25.00

NEXT BUSINESS DAY

(

CANNOT BE BACKDATED

)

FOR DISCONNECTED SERVICES

Electric Breakers and/or Water Valves

must be off.

ADDITIONAL FEES APPLY IF

MULTIPLE TRIP HAS TO BE MADE.

NOTARY INFORMATION:

SUBSCRIBED, ACKNOWLEDGED, AND AFFIRMED

BEFORE ME THIS______DAY OF_____, 20____.

Notary Signature: _____________________

Print Name:

__________________________

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NOTARY

SEAL

OFFICIAL USE ONLY

By signing this document, I have read and understood the terms outlined in the utility billing agreement and the water and sewer line

responsibilities and procedures included with this form on the following pages.

REV08

2019

 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).

o 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 driver’s

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 shall be added to the account

and services will be DISCONNECTED WITHOUT FURTHER NOTICE.

o Once a service HAS BEEN PROCESSED FOR DISCONNECT, IT MUST BE PAID TO THE

TREASURER'S OFFICE.

o An after-hour’s fee shall apply to reconnection of disconnected services for non-payment after

normal business hours.

 Additional fees are added 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, and all collection fees

necessary to collect said bill.

 A customer may request in writing, that their deposit be refunded once good credit has been established by

paying bills 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 and any

other amounts owed to the town (past due balances and/or taxes) will be deducted from the deposit. If a balance

is not owed, the deposit will be refunded to the customer. It is the customer’s responsibility to make sure all

addresses are updated for notification if a balance is due on the account or a refund is owed.

 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 th

e drop box, which is provided for your

convenience outside the Municipal Building at 400 South Main Street, or by our website,

www.culpeperva.gov/payonline.

 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.

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UTILITY BILLING AGREEMENT

August2019

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TOWN OF CULPEPER

WATER AND SEWER LINE

RESPONSILITIES & PROCEDURES

TheTownofCulpeperhaspreparedthissummarizationofWaterandSewerLineResponsibilitiesandProcedurestoinform

ourwaterandsewerutilitycustomersoftheimportanceofpropermaintenanceoftheutilitylinesontheirproperty,andto

provideguidancetocustomersastowhattodointheeventofawaterorsewerlineproblem.Pleaseretainthisinformation

forfuturereference,andshareitwiththoseresponsibleformaintenanceofthehomeorbusinessproperty.

WATER LINE RESPONSIBILITY

The Town of Culpeper is responsible for the operation and maintenance of all water mains and water service lines from

the water main up to and through, but not past, the water meter box. The Town of Culpeper is responsible for all water

meters, angle valves, meter setters, or other appurtenances located before the meter box. Maintenance of the building

service pipe or water service lateral and plumbing within the building is the responsibility of the Property Owner. The Town

of Culpeper has no responsibility for the water service line or lateral on the customer’s side of the meter box.

As soon as the Town of Culpeper is notified of a water leak, it will determine whether the leak is the responsibility of the

Town, as described above. If the leak is the Town’s responsibility, it will be repaired without cost to the customer. If the

leak is found not to be the responsibility of the Town, the customer will be notified to make arrangements for repair by a

plumber at the customer’s expense. The Town of Culpeper will not reimburse the customer for the cost of a plumber or

contractor.

Refer to Town Code Sec. 24-77 for additional information. Any changes to Town Code supersedes the information in this

document. It is the customer’s responsibility to be aware of Town Code changes that may affect their liability.

COURTESY ADJUSTMENTS FOR LEAKS

In the event of a water leak, the customer shall immediately notify the Town of Culpeper at (540) 829-8220. The Town of

Culpeper is not responsible for payment or reimbursement for any work that is done on private facilities.

As a courtesy, the Town of Culpeper offers a billing adjustment for unusually high water consumption due to leaks that

have been repaired in a timely manner once identified. Requests for adjustments must be made to the Utility Billing

Division of the Town Treasurer’s Office within 90 days of the repair. Customers are required to provide a description of

the leak, proof of repair, and other relevant information. Customers should receive acknowledgement of their request

within one week.

Requests related to leaks found in the home are limited to once per year, per customer, per location. Where possible and

appropriate, adjustment related to internal leaks are calculated by crediting 50% of the water and sewer consumption

charges in excess of your average use over the past year.

Requests related to external leaks, such as a leak in the service line to a home or irrigation system, are limited to once

per year, per customer, per location. Where possible and appropriate, adjustments to external leaks are calculated by

crediting 50% of the water consumption charges in excess of your average use plus 100% of the sewer consumption

charges in excess of your average use.

The billing period for all adjustments is limited to the highest bill during the three-month period prior to the repair being

completed.

COURTESY ADJUSTMENTS FOR POOLS

The Town of Culpeper offers a courtesy billing adjustment once a year on sewer consumption charges associated with

filling a pool. As water used to fill a pool typically does not enter the sewer system, adjustments are calculated by crediting

100% of the sewer consumption charges related to filling the pools. Requests for adjustments must be made to the Utility

Billing Division of the Town Treasurer’s Office. Customers are required to provide documentation of their pool capacity.

Requests must be made prior to the pool being filled. Customers should receive a response to their request within one

week.

August2019

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SANITARY SEWER RESPONSIBILITY

The Town of Culpeper is responsible for the operation and maintenance of all sanitary sewer mains up to the point of

connection with the customer’s sanitary sewer lateral or service line. Sewer stoppages in sanitary sewer mains will be

cleared by the Town of Culpeper regardless of cause. The maintenance of sanitary sewer laterals and service lines is the

responsibility of the customer as they are used exclusively by the customer(s) to connect to the Town of Culpeper’s sewer

mains. By definition, a sanitary sewer lateral extends from the connection with the public sewer main all the way to the

customer’s point of use, including the connection itself.

When a blockage occurs in a sanitary sewer lateral or service line, it is the customer’s responsibility to clear any blockage.

The Town of Culpeper has no responsibility for maintenance, repair or replacement of sanitary sewer laterals or service

lines.

SANITARY SEWER RESPONSIBILITY, PRIOR TO ACCEPTANCE INTO TOWN SYSTEM

The Town of Culpeper is not responsible for the operation and maintenance of sanitary sewer mains that have been

constructed and placed in operation but not yet accepted by the Town of Culpeper. The Property Owner or Developer

retains operating and maintenance responsibility as well as liability for sewer backups within areas served by sewer mains

that have not yet been accepted by the Town of Culpeper. When customers are affected, the Town of Culpeper may, at

their sole discretion, assist in the operation and maintenance of sewer mains that are constructed but have not been

accepted by the Town of Culpeper.

SANITARY SEWER BACKUP

If a customer experiences a sewage backup, the Town of Culpeper should be contacted by calling (540) 825-0285 during

business hours or (540) 825-3039 after hours. A representative will be dispatched to determine if the blockage is in the

main. If the Town determines that the main is clear, the customer will be notified that the blockage is their responsibility

and the services of a plumber or contractor should be obtained. The Town of Culpeper will not reimburse the customer

for the cost of a plumber or contractor.

RESPONSIBILITY FOR CLEANUP AND DAMAGE RESULTING FROM SEWAGE BACKUP

The Town of Culpeper is not liable for any sewage backups caused by factors or conditions beyond the control of the

Town. The Town of Culpeper is only responsible for cleanup and property damage if the damage is a result of a sewer

main malfunction, blockage or backup where the Town of Culpeper is legally negligent.

Any cleanup or repairs required to a building as the result of a sewage backup are the responsibility of the

customer or property owner at the customer’s or property owner’s expense and should be filed with the

homeowners or business property insurance coverage provider, as appropriate. Insurance coverage limitations

vary from policy to policy. It is the customer’s and/or property owner’s responsibility to insure they have

adequate insurance coverage to cover their responsibilities.

As a courtesy, with such funds as are appropriated for the purpose, the town will offer to have a cleaning service clean

and disinfect the affected areas at the town's expense, not to exceed $15,000, in the event that a sanitary sewer main

malfunctions, breaks, experiences a blockage, or experiences a surcharged flow, and the result is a backup into a

business or a residence. The town's willingness to offer this assistance shall not be interpreted as an admission of liability;

rather it is designed to protect the health, safety and welfare of the town's inhabitants. The town will only offer this

assistance so long as the impacted business or residence contacts the town before otherwise contracting for this service.

This assistance shall not be available in situations involving sanitary sewer laterals. This service is not guaranteed but

may be offered to reduce the impact of the backup on the affected business or residence. If the customer believes the

Town of Culpeper was liable, the customer should call (540) 829-8290 to speak to the Human Resources Department

who manages the Town’s Risk Management program, and request that an investigation be conducted. If the matter cannot

be resolved, the Town will file a claim with its insurance company who will further investigate to determine if the Town is

liable.

Refer to Town Code Sec. 24-166 for additional information. Any changes to Town Code supersedes the information in

this document. It is the customer’s responsibility to be aware of Town Code changes that may affect their liability.

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