Fill - Free fillable Water Application Water Service Application Form (City of Harker Heights) PDF form

OFFICE USE ONLY:

ACCOUNT #

Initials:

 Deposit Received

 Deposit Waived – Prior History with City of Harker Heights

 Scanned

APPLICATION FOR WATER SERVICE

HARKER HEIGHTS WATER DEPARTMENT  305 MILLER’S CROSSING  HARKER HEIGHTS TX 76548

Today’s Date _____________________________________________ Date to Begin Service ______________________________

RESIDENTIAL SERVICE:

Location of Service _______________________________________________ Phone # _______________________________

Name ___________________________________________________ Spouse _________________________________________

SS# _____________________________________ DL# ______________________________ State ______________________

Mailing Address ____________________________________________________________________________________________

(If different from service address)

E-mail Address _____________________________________________________________________________________________

 Please check here if you would like your bill sent to your e-mail address above.

Place of Employment or Unit in Army ________________________________ Work Phone # __________________________

COMMERCIAL SERVICE:

Location of Service _______________________________________________ Phone # _______________________________

Business Name ___________________________________________ Owner Name ____________________________________

SS# or Tax ID # ____________________________ DL# ______________________________ State ______________________

Mailing Address ____________________________________________________________________________________________

(If different from service address)

E-mail Address _____________________________________________________________________________________________

 Please check here if you would like your bill sent to your e-mail address above.

TERMS FOR SERVICE

The Applicant whose signature appears below applies to the Harker Heights Water Department for water service for the address listed above.

Water service includes water, wastewater, drainage and sanitation services. He/She understands that a $55 deposit is required in order to have

residential service begun in their name; a $200 deposit is required for commercial service. The Applicant agrees to pay for said service as bills are

rendered in accordance with the rates, rules and regulations as provided by the Harker Heights Water Department. Bills include water and

wastewater base and consumption fees as well as base fees for drainage and sanitation. It is the Applicant’s responsibility to contact the Water

Department to terminate services, otherwise the account will continue to be billed and the Applicant will be responsible for all charges.

The Applicant further agrees to release and discharge said Harker Heights Water Department from any liability for damages suffered (1) by

reason of water furnished to the premises, (2) by reason of interruption, discontinuance or disconnection of service hereunder from any cause, or

(3) by reason of the condition, maintenance, location or existence of any of the facilities, fixtures, or systems located on or adjoining the property

supplied and by which such services are furnished or delivered.

IMPORTANT: For our mutual protection, we require someone to be present the day the water is scheduled to be connected. This is to avoid

the possibility of flooding the home. If someone is not present when the water is connected, a second trip may be necessary to connect services.

This will result in a $25 fee added to the first bill.

No person(s) other than Water Department employees are authorized to turn water on or off. Penalty for violation is a fine of up to $500.

There will be a $30 charge on all returned checks.

If charges are not paid by the delinquent date a $15 late charge will be added to the account.

I hereby apply for service in accordance with the terms above. I further understand that information provided on this application is necessary to

provide me with the services necessary in support of this application and to contact me in case of a water emergency.

Signature _____________________________________________________________________ Date:

Print Form

RESIDENTIAL CUSTOMERS ONLY:

The City of Harker Heights Water Department is a government operated utility. Information in your customer account record is

generally considered public information under Texas Government Code, Chapter 552 (Public Information Act). However, the Texas

Utilities Code, Chapter 182 (Rights of Utilities Customers) provides that a government-operated utility may not disclose personal

information or any information relating to the volume or units of utility usage or the amounts billed to or collected from a customer for

utility usage, if the customer requests that the government-operated utility keep the information confidential.

A request for confidentiality under Chapter 182 does not prohibit a government-operated utility from disclosing personal information

in a customer’s account record to (1) an official or employee of the state, a political subdivision of the state, or the United States acting

in an official capacity; (2) an employee of a utility acting in connection with the employee's duties; (3) a consumer reporting agency;

(4) a contractor or subcontractor approved by and providing services to the utility, the state, a political subdivision of the state, or the

United States; (5) a person for whom the customer has contractually waived confidentiality for personal information; or (6) another

entity that provides water, wastewater, sewer, gas, garbage, electricity, or drainage service for compensation.

(Initial) I request that any information relating to my account (personal information and information regarding the volume

or units of usage or the amounts billed to or collected from me) be kept confidential under Texas Utilities Code, Chapter 182. I

understand that a government-operated utility or an officer or employee of a government-operated utility is immune from civil liability

for a violation of Texas Utilities Code, Subchapter B.

The following person(s) other than the names listed on the reverse side may have access to my account.

DRAFT AUTHORIZATION

Drafting of your credit/debit card or bank account is an OPTIONAL service offered by the Harker Heights Water Department. If you

choose to have your payment drafted, please SELECT ONE of the options below.

OPTION 1: CREDIT/DEBIT CARD DRAFT

Credit/Debit Card Number:  VISA  M/C  Discover  AMEX Exp. Date:

Name as it Appears on Credit Card:

Billing Address & Zip Code for Credit Card:

OPTION 2: BANK ACCOUNT DRAFT -- A voided check or bank card copy is REQUIRED for drafts from a bank account.

Name(s) on Account:

Bank Name: Routing #: Account #:

Please initial by each applicable statement:

ALL DRAFTS: I authorize the City of Harker Heights to draft the account indicated above to pay my monthly utility bill. I

understand that the account will be drafted for the total amount due on the due date referenced on my bill.

ALL DRAFTS: I understand that I must make payments on my account until “PAID BY CREDIT CARD” OR “PAID BY

DRAFT” appears on my City of Harker Heights utility bill. Failure to do so could result in late fees.

ALL DRAFTS: I understand that this authorization will remain in effect until the City of Harker Heights receives written

notification of its termination.

BANK DRAFTS ONLY: I understand that I must pay my current bill and the next bill in order to allow time for my bank

draft to be set up. Bank drafts have to be pre-noted which can take up to one billing cycle.

BANK DRAFTS ONLY: I understand that, if my draft is returned for insufficient funds or closed account, I will be

charged a fee of $30. I will also no longer be permitted to have my account drafted nor pay by check for six months. After six months,

I will need to submit a new automatic draft authorization in order to start drafts again.

CREDIT CARD DRAFTS ONLY: I understand that I am responsible for providing accurate information concerning my

credit card account and for contacting the Harker Heights Water Department with any changes to include the name on the card, credit

card number, billing address, and/or expiration date. Failure to provide accurate information could cause the card to decline the charge

and I will be responsible for making a payment in another form to include any late fees applied. After my draft is returned two times,

the draft will be removed from my account and I will need to make payments on my account as usual.

Fill Online, Printable, Fillable, Blank Water Application Water Service Application Form (City of Harker Heights) Form

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Fillable Water Application Water Service Application Form (City of Harker Heights)

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