Utility Service Agreement (Move Outs, New Residents, Address Changes)

Billing Name *

Billing Address *

Service Name *

Service Address *

Owner Name *

Owner Address *

Email

Contact Number

#1 Resident/Occupant Name

#1 Resident/Occupant Social Security Number (Income Tax Department)

#1 Resident/Occupant Place of employment (Income Tax Department)

#2 Resident/Occupant Name

#2 Resident/Occupant Social Security Number (Income Tax Department)

#2 Resident/Occupant Place of Employment (Income Tax Department)

Start Date for Water/Sewer Service *

Prior Address

Any Additional Information

I(WE) THE UNDERSIGNED APPLICANT(S) FOR WATER AND/OR SEWER UTILITY SERVICE, UNDERSTAND THE TERMS AND CONDITIONS OF SUCH SERVICES AS PRESCRIBED IN THE CODIFIED ORDINANCES, PART NINE: TITLE THREE, OF THE CITY OF LOUISVILLE AND AGREE TO ABIDE BY SAID PROVISIONS. I (WE) HEREBY SWEAR OR AFFIRM THAT I(WE) OWN THE REAL ESTATE TO BE SERVICED BY THE WATER AND/OR SEWER UTILITY SERVICES DESCRIBED IN THIS AGREEMENT.

LOUISVILLE CITY ORDINANCE 931.021 STATES THAT THE REAL ESTATE OWNER IS LIABLE FOR ALL SERVICE CHARGES AND APPLICABLE BILLS/INVOICES WILL BE SENT DIRECTLY TO THE REAL ESTATE OWNER. IF THE PROPERTY IS A RENTAL, IT IS THE REAL ESTATE OWNER’S RESPONSIBILITY TO PAY THE BILL OR PASS THE BILL ALONG TO THE TENANT(S) ACCORDINGLY.

Signature *