City of Cottonwood Municipal Water & Wastewater Utility

Contract for Water and Wastewater Service

Date Service Desired*

Email Address*

First Name*

Middle Name

Last Name*

Phone Number - Primary (numbers only, no dashes)*

Phone Number - Secondary (numbers only, no dashes)

Driver's License/ID#*

State of Issuance*

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Expiration Date*

Upload a copy of your US Government Issued picture ID*

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Service Address (House Number)*

Service Address (Street Name)*

Service Address (City)*

Service Address (State)*

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Service Address (Zip Code)*

Mailing Address (House Number)*

Mailing Addresss (Street Name)*

Mailing Address (City)*

Mailing Address (State)*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Mailing Address (Zip Code)

Role*

Owner Realtor

Renter Business

Landlord/Property Management

Customer Acceptance

I, the undersigned, hereby make contract to THE CITY OF COTTONWOOD UTILITY DEPARTMENT for water and sewer services. I agree to pay for such services at the established rates for my usage classification, and in accordance with all rules and regulations as approved by THE COTTONWOOD CITY COUNCIL. I agree to use such services for my own purposes and further agree not to sell any part of the same, or permit such services to be used for any other purpose other than for my own purpose as allowed in my usage classification. I agree not to tamper with, or modify the water valve contained within meter box. I agree that the duly authorized agents and employees at said CITY shall have access to my premise at all reasonable hours for the purpose of installation or removal of meters, and inspection of equipment incidental to carrying out this agreement, and I further agree to hold THE CITY OF COTTONWOOD harmless for from any claims, real or alleged, for loss or damage to property or persons arising out of the delivery of services beyond the point of the metering.

I agree to give the said CITY 1 business day notice prior to vacating the premises and discontinuation of services. In the event of failure on my part to comply with the terms of this contract, I agree that said CITY, or its representatives, may discontinue services here under without further notice to me, and that discontinuance will not constitute waiver of any claims against me for prior services rendered here under by said City. I also agree that if my account is sent to a collection agency as of my failure to pay that I will be liable for the collection agency fees and the outstanding amount due the CITY.

You have signed up for Water/Wastewater services. This account is in your name and is your responsibility. Should you experience a leak of any kind at the property you own/rent, you will be liable for associated charges, and it will be up to you to work out reimbursement of the water bill with the property owner (your landlord or property management company). Charges for leaks will be billed to you and will remain your responsibility. (INITIALS)*

A Security deposit is due when service is established. The deposit can be waived if the any of following terms are met:
1. The customer has an existing open account showing no late fees or charges in the past twelve (12) months.
2. The customer has closed an account within the prior six months with no late fees or charges for the prior (12) months on the account.
3. The applicant completes and submits an auto withdrawal form with the application or enrolls in auto pay before the first billing.(If the customer cancels the auto withdrawal within the first 12 months the $100 security deposit will be required to maintain service). Waiver of security deposits shall be at the discretion of the utility department.
Your security deposit is refundable after twelve (12) full months good payment history. Good payment history means NO late payments in twelve (12) months of consecutive billing. Your payment history will be automatically reviewed . Your security deposit will be credited to your account or applied to your final bill, whichever comes first. If you received assistance from a social service agency any refunds will go back to that agency up to the amount given for your assistance. (INITIALS)*

Signature (Type your full name to signify your agreement to all terms)*

Date*

Last four digits of Social Security Number - To be used as a pin number for identification.