Fillable Utility Services Application R2021 (City of Cedartown)

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Utility Services Application R2021 (City of Cedartown)

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The Utility Services Application R2021 (City of Cedartown) form is 2 pages long and contains:

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  • 41 other fields

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File type: PDF

U.S.A. forms for City of Cedartown

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** Nine (9) days or less will be prorated **
*** Ten (10) days or more constitute a full billing period with no proration of any applicable rate ***
Account Number:
______________________
UTILITY SERVICES APPLICATION
Phone: (770) 748-3220 Fax: (770) 748-8962
Email: jrice@cedartowngeorgia.gov
Applications will not be accepted or water service turned on without the following:
1.
Picture identification: Driver’s license, state ID or passport
2.
Rental/lease agreement or ownership paperwork. Note: rental/lease agreement must
contain the owners name, signature and telephone number.
3.
Deposit:
Homeowners - $100
Rental/Lease - $100 deposit & $50 non-refundable fee
$15 fee
Date turn off:
Name:
Service
Address:
Maiden
Name:
Date Service
Requested:
Mailing Address (if different from above):
Telephone:
Occupants living in household:
Cell Phone:
1.
Email Address:
2.
Date of Birth:
SSN:
3.
Have you previously had service with the City of Cedartown?
Yes No
If YES, please list address(s):
Employer:
Telephone:
Co-occupant:
SSN:
Employer:
Telephone:
Emergency Contact (not living with you):
Relationship:
Telephone:
All water bills are due and payable by the 10
th
of the month, if the bill is not paid by this date, an automatic 10% late
charge will be added to the past due balance and the total bill amount becomes due before the 25
th
of the month
following the billing date. Applicant is responsible for all charges until service is terminated. If a past due amount is
shown on the bill, the full amount due must be paid or service will be discontinued without further notice. Additional
charges will apply for restoration of service and any other costs incurred in settling your account. Failure to receive a
bill does not entitle delayed payment. There will be a $30 charge for all checks returned. Service charges established
by the City of Cedartown may be added to the customer’s account to cover the costs of collection efforts.
I understand and hereby agree to the following: (1) falsification of any of the above information may result in the
immediate disconnection of service without notice; (2) failure to pay account in accordance with the City of
Cedartown’s policies will result in the disconnection of service; (3) all water going through the meter is the customer’s
responsibility – if you have leak protection, a cost adjustment on the water/sewer portion of the bill up to $750 upon
submittal of repair receipt or plumber’s bill and verification of repair; (4) failure to pay final bill will result in account
being submitted to collections – I will as a result, be responsible for all charges and collection costs; (5) no one living in
my household has an outstanding balance owing the City of Cedartown; (6) water is temporarily connected until
records have been verified and approved.
Signature:
Date:
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signature
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** Nine (9) days or less will be prorated **
*** Ten (10) days or more constitute a full billing period with no proration of any applicable rate ***
Account Number:
______________________
UTILITY SERVICES APPLICATION
Phone: (770) 748-3220 Fax: (770) 748-8962
Email: jrice@cedartowngeorgia.gov
UTILITY BILLING AND GARBAGE COLLECTION
NEW ACCOUNTS:
• Customer must be at least 18 years of age. (If customer is younger, he/she must present proof of full-time job
and parent/guardian will need to co-sign with customer.)
• Customer must report to office in person to sign for service.
• Customer must have a picture ID, such as a driver’s license.
• Customer must provide proof of ownership of property or rental/lease agreement.
• Customer must be prepared to pay security deposit.
• In order to receive next day service, customer must fulfill the above requirements.
• In order to have service connected, customer must be present and provide a time they will be at the
address.
GARBAGE SERVICE
RESIDENTIAL:
POLYCARTS
$13.50 per cart, per month
# of carts
COMMERCIAL:
POLYCARTS
$27.00 per cart, per month (Limit 2 polycarts)
# of carts
LEAK PROTECTION POLICY
By signing below, I attest that I am the account holder and I am voluntarily choosing to
ACCEPT
CANCEL
Initials
Initials
The Leak Protection Policy offered by the City of Cedartown.
I understand that I am solely responsible for payment of all water/sewer bills for my account and if I choose to
CANCEL leak protection that I am NOT ELIGIBLE for any leak adjustment(s) due to leak(s) that occur at my residence
and/or business.
A copy of this letter will be maintained at the City of Cedartown. Should you wish to change this protection, you
must complete another waiver.
Signature of Account Holder
Date
I would like to receive account notifications by:
PHONE
TEXT
*message & data rates may apply
By signing below, I acknowledge I have received a copy of the Water Service Policy and the Leak Protection Policy.
Signature of Account Holder
Date
Witness
Date
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Utility Services Application R2021 (City of Cedartown)

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Completed 18 January 2021

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