City of Mineral Wells ♦ 211 SW 1st Avenue ♦ Mineral Wells, TX 76067
Phone Number (940) 328-7720 ♦ Fax Number (940) 328-7732
waterbilling@mineralwellstx.gov
WATER TRANSFER REQUEST
I ACKNOWLEDGE THAT MY PRESENCE IS REQUIRED FOR CONNECTION OF SERVICE. IF CONNECTION OF SERVICE IS
NOT POSSIBLE DUE TO RUNNING WATER, YOU MUST RESCHEDULE CONNECTION AND A $25.00 SERVICE CALL FEE
WILL APPLY. PLEASE COMPLETE ALL FIELDS POSSIBLE TO AVOID DELAYS IN WATER SERVICE ACTIVATION.
_______________________________________________________
Applicant Signature Date
Do you wish your personal information to be confidential? Yes No
I am at least 60
years of age and request the Late Penalty Exemption.
Date to Open NEW Account: _____________________________________
Name: __________________________________________________________________________________
Social Security# (last 4 digits): _____________ Driver’s License or ID: _______________________________ State: _______
Date of Birth: _______________ Home Phone: ___________________________ Work Phone: __________________________
Email: __________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________
Spouse/Next of Kin: _____________________________________________________________
Home Phone: ______________________________________ Work Phone: ___________________________________
Do you rent ( ) or own ( Landlord’s Name: ____________________________ Phone: _____________________
OLD Service Address: ______________________________________________________________________________
Date to Cutoff OLD Service: ________________
NEW Service Address: ______________________________________________________________________________
OFFICE USE ONLY
Account#:
Input By:
Deposit Amount/Receipt#:
C/O Paid: Yes No
C/O Approved:
Lease or Proof of Ownership:
A $40 TRANSFER FEE WILL BE ADDED TO THE NEW ACCOUNT.
The old service can only be on for 7 days after the new service starts. We can only leave service turned on at both places
for a maximum of 7 days.
Transfer Fee Applied
Sewer Transfered
click to sign
signature
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