Fillable Water / Sewer Service Application - Tenant (Town)

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Water / Sewer Service Application - Tenant (Town)

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

  • 2 signatures
  • 6 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town

BROWSE TOWN (VA) FORMS

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102020
TENANT INFORMATION Tenant 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
☐ 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.
DEPOSIT & FEES
Cash or Check Only TENANT DEPOSIT: $ _______________ + ADMINISTRATIVE FEE: $ 35.00
Tenant Deposit: Please contact the Town Office to receive the Tenant Deposit amount, which is equal to the 3 prior months of user fees at the service
location. The Tenant Deposit will be applied to the Tenant’s Final Bill when discontinuing service at the provided address.
Administrative Fee: The Administrative Fee is non-refundable and in addition to the Tenant Deposit.
TENANT SIGNATURE
TENANT PRINTED NAME
DATE
PROPERTY OWNER INFORMATION
FIRST & LAST NAME OR BUSINESS NAME
MAILING ADDRESS
PHONE NUMBER
EMAIL ADDRESS
ACCOUNT DELINQUENCY
☐ YES, I would like to be notified at the above email address whenever the listed tenant becomes 15 days delinquent.
☐ NO, I would not like to be notified at the above email address whenever the listed tenant becomes 15 days delinquent.
Affirmation:
__________________________________________ (Tenant Name) has entered into a lease for property located at
_________________________________ (Property Address) and is authorized to obtain services at the provided
address as a tenant of ______________________________ (Property Owner Name), effective the service start date
provided above.
PROPERTY OWNER SIGNATURE
PROPERTY OWNER PRINTED NAME
DATE
TENANT APPLICATION
WATER / SEWER SERVICE ACCOUNT
new
PO BOX 187, MIDDLEBURG, VA 20118 ׀ MIDDLEBURGVA.GOV ׀ (540) 687-5152
Application to request account activation for established water and sewer service.
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Water Sewer Service Application - Tenant (Town)

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Completed 23 January 2021

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