Fillable Utility Service Membership (CITY OF PIEDMONT)

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Utility Service Membership (CITY OF PIEDMONT)

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U.S.A. forms for CITY OF PIEDMONT

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************************************* Office Use Only: ***********************************
Water: □ On □ Off Trash: Has _______ PC’s and wants ______.
Utility Service Membership
Account #: _________________ Date ________
Date to start service (Mon-Fri) :________________
Location Address: __________________________________________________________________________
Legal Description: __________________________________________________________________________
Mailing Address (if different): _______________________________________________________________
Previous Address: _________________________________________________________________________
Number of Persons occupying premises: _____________ Sewage Disposal: ☐ City or ☐ Septic
If this is a rental property, homeowners name: ______________________________________________
If this is a rental property please request a Supplemental Users Agreement to fill out.
Please complete as much of the following information as possible)
Name: ___________________________________________ Email: __________________________________
Home phone: __________________________________ Cell phone: ________________________________
SSN: ___________________________ DL #: ___________________________ State: __________________
Employer: __________________________________________________________________________________
Employer Address: ________________________________________ Work Phone #: __________________
Spouse/Co-Occupant Name: ___________________________________________ Cell #: _____________
SSN: __________________________ DL #: ____________________________ State: __________________
Employer: __________________________________________________________________________________
Employer Address: _____________________________________________ Phone #: __________________
Have you ever had service with us? _______ If so, when: ______________ Location:_____________
Personal Reference: __________________________________ Phone: ______________________________
WATER, SEWER AND/OR WASTE DISPOSAL USERS AGREEMENT
This agreement entered into between the Piedmont Municipal Authority and the occupant signing below is
hereby understood and agreed by both parties as follows:
• The Piedmont Municipal Authority will provide, subject to the limitations set out in its rules and
regulations now in effect or hereafter amended, and subject to availability, such quantity of water and/or
waste disposal service as the occupant may desire in connection with the occupancy of the described
property.
• The occupant agrees to comply with and be bound by the rules and regulations of The Piedmont
Municipal Authority, now in force or hereafter legally supplemented and/or amended. The occupant also
agrees to pay for water, sewer, and/or waste disposal service at such rates, time and place as shall be
determined by The Piedmont Municipal Authority. The occupant also agrees to pay any penalties incurred
for non-payment of the utility bill.
• The occupant is responsible for any charges incurred due to damages inflicted on PMA property, including
but not limited to damage to the water meter, meter box, main line, transfer line, meter valve and/or
meter lock.
• The Piedmont Municipal Authority shall have final authority in any question of location of service line
connection to its water distribution and/or waste water collection system; shall determine the allocation
of water to the occupant in the event of water shortage and may shut off water to occupant if allowing a
connection or extension to be made to service line that has not been approved by the Piedmont
Municipal Authority or for the purpose of providing water to another user.
• In the event the water supply shall be insufficient to meet the needs of the occupant or there is a city
wide shortage, The Piedmont Municipal Authority may limit the water available or put restrictions on
usage for certain occupants, as approved by the Board of Trustees and the occupant agrees to follow the
necessary restrictions when put in place.
• The failure of the occupant to pay their water, sewer, and/or waste disposal charges shall result in the
following penalties:
1. Non-payment of charges by due date will be subject to a ten percent penalty (10%) of the past
due amount.
2. Non-payment of the charges within thirty (30) days from the due date may result in the utility
services being shut off or discontinued.
3. In the event it becomes necessary for PMA to shut off the water service or discontinue trash
pick-up due to non-payment, a $40.00 reconnection fee will be applied to the occupants
account.
4. Non-payment of the balance for a period of sixty (60) days or more shall constitute a termination
of this agreement and all rights of the occupant to water, sewer, and/or waste disposal service
shall terminate. Upon such termination, The Piedmont Municipal Authority may take such
actions deemed reasonable and necessary to collect balance owed, including all penalties, plus
all court costs and attorney’s fees incurred thereafter.
5. If, for any reason, your water meter is pulled due to the customer’s request or for non-payment,
there will be a $300.00 fee to be paid in order to get the meter reset.
The Piedmont Municipal Authority has no liability to the occupant for disruptions of service due to water breaks,
weather, catastrophic events, or any other events beyond the reasonable control of the Piedmont Municipal
Authority. The occupant releases The Piedmont Municipal Authority of any liability for damages caused by the
operation of the water, sewer, and/or waste disposal systems.
Aut
omatic Bank Withdrawal: Payments will be drafted on the 15
th
of every month. If the 15
th
falls on a weekend,
the draft date will be posted on the following Monday. Balance must be paid in full to set up Automatic Bank
Withdrawal. All changes to the customer’s automatic bank withdrawal have to be completed before the 1
st
of
each month. Any changes after this date will be effective on the next month’s billing.
Pa
yment Options:
1. Online at www.municipalonlinepayments.com/piedmontok
2. Call 1-877-717-4656
3. Dropbox on the south side of the civic center. It is checked on a daily basis. If the due date falls
on a Friday or weekend, you must have your payment in the box by 8am on the following
Monday morning in order to avoid a penalty.
4. Bring your payment into the office during business hours.
Water Meter Readings: The normal read date for all meters is around the 15
th
of every month. If for some reason
you believe that your reading was incorrect, the customer is responsible for contacting the Piedmont Municipal
Authority to ask for a re-read before the 15
th
of each month. After the 15
th
, it is not guaranteed that a re-read can
be completed.
Trash: Please put your trash out by 6:00 am on your trash day. If it does not get picked up on that day, please
contact us the following morning and let us know. We will contact the trash company at that time. Due to some
dirt road conditions, the trash company reserves the right to use their discretion on trash pick-up during
inclement weather for the safety of their equipment and staff. Please remember the trash company is
subcontracted through the City of Piedmont.
We recommend each customer signs up for the City’s CivicReady program to receive notices on holidays and
delayed trash pick-up. Visit piedmont-ok.gov for more information.
The City of Piedmont provides spring and fall clean-up days for your trash service. Customers will be notified by
mail.
If you have any further questions, please feel free to contact our Utility Billing Coordinator, Christen, at
(405) 373-2000 or e-mail christenh@piedmont-ok.gov.
By signing this membership agreement, I agree to comply with and be bound by all rules and regulations of the
Piedmont Municipal Authority and to pay any and all fees, assessments and other lawful amounts chargeable by
members.
Executed this _________ day of ___________________, 20 __________.
_______
__________________ _________________________ _________________________
Signature of Occupant Signature of Co-occupant Piedmont Municipal Auth
Utility Billing Coordinator
FOR OFFICE USE ONLY:
RECEIVED THIS _______ DAY OF ________________, 20 ________. RECEIPT NUMBER: ___________________________
DEPOSIT AMOUNT PD: _______________ CASH: _________ CHECK: _________ CHECK NUMBER: __________________
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Utility Service Membership (CITY OF PIEDMONT)

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Completed 19 January 2021

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