Application for Utilities

This information will be considered strictly confidential and will be used only as appropriate for maintaining and collecting utility bills.

Date of Application:	Date Service Requested:

The deposit for utility service is $100.00.

Deposits shall be retained until at least six months of on time payments can be demonstrated. Should six months of timely payments not be demonstrated prior to the termination of a customer’s utilities, any deposit shall be applied first to any outstanding balance prior to being returned, or applied to a subsequent property, as directed by the customer.

Name:	Date of Birth:
Mailing Address:	Service Address:
Phone #:
Driver’s License #:	Verified ☐
Social Security #:	Verified ☐
Name of Employer:	Employer’s Phone #
If Rental, Name & Address of Landlord:
Emergency Contact Person:	Phone:

Applicant’s Signature:	Date:

The City of Terrytown will notify my landlord and any third party named below, of any potential utility disconnection. Pursuant to Terrytown Municipal Code, landlords are jointly responsible for any unpaid utilities.

“This institution is an equal opportunity provider”

“Esta institución es un proveedor de servicios con igualdad de oportunidades”.

A copy of your Driver’s License or State ID Card is required.

Utility Deposit Payment Date: Amount Paid: Cash ☐ Check ☐
I have received a copy of the Utilities Information. Customer Initials:

Third Party Notification The City of Terrytown may notify my landlord, or the third party listed below of any proposed discontinuance of utility services, and further accepts responsibility for unpaid bills.	Initials
Name:
Address:
Phone: