Fillable Water / Sewer Service Application - Property Owner (Town)

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Water / Sewer Service Application - Property Owner (Town)

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The Water / Sewer Service Application - Property Owner (Town) form is 1 page long and contains:

  • 1 signature
  • 4 check-boxes
  • 10 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town

BROWSE TOWN (VA) FORMS

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102020
PROPERTY OWNER INFORMATION Photo ID Required with Application
FIRST & LAST NAME OR BUSINESS NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL ADDRESS
SOCIAL SECURITY NUMBER OR FEDERAL ID NUMBER
DRIVERS LICENSE NUMBER
SERVICE LOCATION
PROPERTY ADDRESS
SERVICE USE TYPE
SERVICE START DATE
☐ COMMERCIAL ☐ RESIDENTIAL
BILLING Select one
☐ eBILL I would like to receive my bill electronically (eBill) to the email address provided. Paper bills will not be mailed via USPS until
notification to discontinue the eBill service is received.
☐ MAIL I would like to receive a paper bill to the mailing address provided.
FEES
Cash or Check Only ADMINISTRATIVE FEE: $ 35.00
Administrative Fee: The Administrative Fee is non-refundable.
NOTICE
In the event the service address listed above is rented/leased to a Tenant, who is given permission by the Property Owner listed to obtain water
and sewer services in said Tenant’s name, the Tenant must complete the Tenant Application for a Water / Sewer Service Account. When the
Town of Middleburg is notified to discontinue service under a Tenant’s name, a Final Bill will be mailed to the Tenant and the account will be
activated in the Property Owner’s name until such time a new Tenant Application has been submitted. Any water/sewer usage during the
transition period will be billed to the Property Owner.
PROPERTY OWNER SIGNATURE
PROPERTY OWNER PRINTED NAME
DATE
PROPERTY OWNER APPLICATION
WATER / SEWER SERVICE ACCOUNT
new
Application to request account activation for established water and sewer service.
PO BOX 187, MIDDLEBURG, VA 20118 ׀ MIDDLEBURGVA.GOV ׀ (540) 687-5152
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Water Sewer Service Application - Property Owner (Town)

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Completed 23 January 2021

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