Application for Residential Utility Services

APPLICATION FOR COMMERCIAL UTILITY SERVICES

FOR THE CITY OF COLLINSVILLE

PLEASE PRINT CLEARLY

THE CONSUMER SHALL BE RESPONSIBLE FOR ALL DAMAGE TO, OR LOSS OF, THE CITY’S PROPERTY LOCATED UPON THE CONSUMER’S PREMISES, UNLESS OCCASIONED BY CAUSES BEYOND THE CONSUMER’S CONTROL. THE CONSUMER SHALL NOT AUTHORIZE ANYONE TO CHANGE, REMOVE OR TAMPER WITH THE CITY’S PROPERTY. FRAUDULENT USE OF UTILITY SERVICES OR TAMPERING MAY SUBJECT THE CONSUMER TO CRIMINAL AND CIVIL PROSECUTION. DEPOSITS ARE RECEIVED SUBJECT TO AVAILABILITY OF SERVICE.

Name of Firm ______Fed Id #______

Service AddressBusiness Phone

Mailing Address______

(If different than service address)

Responsible Party Name ______

Home Mailing Address______Home Phone______

DOB______SS#______DL#______

Nearest Relative’s Name ______Relationship______

Address ______Phone#______

City St Zip

Personal reference______Relationship______

(Other than a family member)

AddressPhone#

City St Zip

Have you ever had service with the City of Collinsville? YESNOIf yes, when?__

What was the address______

Street Address City St Zip

If you are a renter – Landlord’s name, address and phone number ______

______

THE UNDERSIGNED AGREES TO PAY THE ESTABLISHED RATE SET FORTH BY THE CITY OF COLLINSVILLE AND AGREES TO REGULATIONS GOVERNING SAID SERVICE. THIS APPLICATION BECOMES A CONTRACT UPON THE ESTABLISHMENT OF SERVICE. UTILITY SERVICES WILL NOT BE PROVIDED TO ANY CUSTOMER WHO OWES MONEY TO THE CITY OF COLLINSVILLE WITHOUT THE PAST DUE ACCOUNT FOR WHICH THE MONEY IS OWED BEING MADE CURRENT FIRST. I/WE CERTIFY THAT I/WE HAVE RECEIVED A COPY OF THE AGREEMENT AND AGREE TO ABIDE BY THE TERMS AND CONDITIONS AS SET FORTH.

______DATE______

SIGNATURE

______DATE______

SIGNATURE

******FOR OFFICE USE ONLY******

DEPOSIT AMOUNT $OWNERRENTER__

RECEIPT#______

ACCOUNT#______

* Two forms of ID and a copy of the lease agreement or deed is required. *

The UNDERSIGNED shall hereinafter be referred to as “APPLICANT” ,“UTILITY SERVICE” or “UTILITIES” shall mean electric service and /or water/sewer services. “CITY” shall mean City of Collinsville and /or its authorized agents or employees. “CONSUMER” shall mean applicant or any occupant of the premises.

The applicant must make deposit at the time of application with the city for the purpose of guaranteeing payment of the monthly utility bill. The City reserves the right to require additional deposit amounts in the event the initial deposit amount is inadequate or in the case of a delinquent payment history.

The consumer shall give authorized agents of the City permission to enter the consumer’s premises at all reasonable times for any purpose incidental to the supplying of utility services, including tree trimming and removal, and meter reading. Refusal on the part of the consumer to provide reasonable access for the above purposed shall be deemed sufficient cause for discontinuance of service.

The City will mail a bill to the service address or other designated mailing address around the 25th of each month. This bill is due in full by 10th of the month. A penalty of 10% will be added to any account not paid by the due date. All bills become delinquent if not paid in full by the 21st of the month. The City may disconnect service without further notice. A service fee of $50.00 will be charged on any service that is disconnected for non-payment. This fee must be paid in full, together with all amounts then due, before the reconnection of service. Payments tendered under these circumstances must be paid by cash, money order or cashier’s check. No personal checks will be accepted. FAILURE TO RECEIVE A BILL DOES NOT ENTITLE PAYMENT WITHOUT PENALTY. The reconnection of services may be done during the office hours Monday through Friday, 8:30 a.m. to 5:00 p.m. After hours reconnection may be made at the City Police Department Monday through between 5:00pm – 9:00pm. An additional $150.00 will be charged for after hours reconnection. All payments and associated fees must be paid in full by money order or cashier’s check for after hour’s reconnection.

Any consumer issuing check, draft or other order to the City of Collinsville that has not been honored for any reason shall be charged a service fee of $20.00 for proper handling and administrations. A $25.00 collection fee will be charged for notification of a returned check or draft. Such check or draft or other order must be honored by 9:30 a.m. of the first business day following notice to the maker, and the service fee must be paid at this time in the form of cash, money order or cashier’s check. Failure to do so shall result in disconnection of utility service. Notice from the City to the maker may be given by telephonic communication or delivered to the premises. Said notice of dishonored check; draft or order shall be the only notice given prior to disconnection of utility service. Two such dishonored items may result in the consumer being required to make future payments by cash, money order, cashier’s check or Visa/MasterCard.

Once service has been turned off in the applicant’s name, the City will apply the deposit to the final bill. If a credit balance remains, the City will mail a check to the applicant. If there is a balance due, the City will mail out a final bill to the applicant. Failure to pay the final bill by said due date will result in the account being sent to a collection agency of the City’s choice. Applicant will be responsible for the original bill amount plus any costs associated with collection of the account.

The City may disconnect utility service to a consumer for the reasons set forth below:

1. Non-Payment of bill

2. Refusal of consumer to provide reasonable access to City equipment on the premises.

3. Failure of the consumer to make application for service.

4. Failure of the consumer to make application in the true name of the consumer for the purpose of avoiding payment of an unpaid obligation for utility service.

5. Failure of a consumer to honor any check, draft or order which has been returned to the City as non-payable. (i.e. insufficient, account closed, stop pay etc….)

6. Failure of the consumer to post additional deposits as may be required.

7. Violation of any rule or regulation of the City or non-compliance with any applicable Federal, State, Municipal or other local laws, rules or regulations.

8. Violation of or non-compliance with an approved rule service of the City (these Terms & Conditions of Service, non-inclusive)

9. Existence of a dangerous or defective condition of wiring or equipment on consumer’s premises.

10. Fraudulent use of utility service.

11. Tampering with the City regulating and measuring equipment of other property.

The consumer shall be responsible for all damage to, or loss, of City’s property located upon the consumer’s promises, unless occasioned by cause beyond the consumer’s control. The consumer shall not authorize anyone to change, remove or tamper with the City’s property. Fraudulent used of utility services or tampering may subject the consumer to criminal and civil prosecution.

SIGNATURE ______

In an effort to decrease costs associated with the collection process, the City of Collinsville would like to announce some changes that may affect your utility bills.

Beginning March 2007, the processing/disconnect fee will change to a $50.00 processing fee. Accounts not paid in full before the disconnect date will be assessed the $50.00 processing fee.

Beginning July 2007, ALL UTILITY BILLS WILL BE DUE THE 10TH OF EACH MONTH. Moving the due date to the 10th of each month allows extra days to pay the bill. If payment is not in the office by the 10th of each month, a 10% late fee will be assessed. If the payment plus the late fee is not in the office by the 21st of each month, a $50.00 processing fee will be assessed to the account. Utilities will be disconnected on the first business day after the 21st of each month. If your utilities are disconnected, all payments and associated fees must be paid in full by cash, money order, cashier’s check or Visa/MasterCard before reconnection can be made.

The City of Collinsville offers after hour’s reconnection through the Collinsville Police Department located at 1023 W. Center. After hours reconnection can be made Monday – Friday 5:00pm – 9:00pm. The fee for after hour’s reconnection is $150.00. All payments and associated fees; including the after hours fee, must be paid in full before reconnection can be done. After hours reconnection payment can only be made by a money order or cashier’s check.

Payments can be made in the utility office Monday - Friday 8:30am – 5:00pm. The City of Collinsville offers payment by bank draft, credit card and the average monthly billing plan and drop box.

For your convenience the night drop is located between City Hall and the Fire Department. The drop box is collected at 8:30am. Any payment dropped after this time will be posted the next business day. Please do not put cash payment in the night drop. If your utilities are in jeopardy of being disconnected or already have been disconnected, please do not put your payment in the night drop. Please bring the payment into City Hall.

The City of Collinsville offers automatic bank draft from your checking account. Simply bring in a voided check and fill out an automatic draft application. In addition, if you sign up for automatic draft now, your payment will not be drafted until the 21st of each month giving you an extra 11 days to pay with no penalties!

The fee for any returned check or auto draft is a $20.00 return check fee and a $25.00 collection fee. If the original check amount plus all fees are not paid by the date of notice, utilities will be disconnected and an additional $25.00 will be due. All monies for returned items must be paid with cash, money order, cashier’s check or Visa/MasterCard.

If you are having trouble paying your bill, please contact the utility office BEFORE the due date. Payment arrangements can be made twice a year. All payment arrangements must be made by account holder in person in the Utility office before the disconnection date. No arrangements will be made on or after the disconnection date.

Please call City Hall at 371-1010 8:00am – 5:00pm if you have any questions or concerns.

Thank you.

The City will mail a bill to the service address or other designated mailing address around the 25th of each month. This bill is due in full by 10th of the month. A penalty of 10% will be added to any account not paid by the due date. All bills become delinquent if not paid in full by the 21st of the month. The City may disconnect service without further notice. A service fee of $50.00 will be charged on any service that is disconnected for non-payment. This fee must be paid in full, together with all amounts then due, before the reconnection of service. Payments tendered under these circumstances must be paid by cash, money order or cashier’s check. No personal checks will be accepted. FAILURE TO RECEIVE A BILL DOES NOT ENTITLE PAYMENT WITHOUT PENALTY. The reconnection of services may be done during the office hours Monday through Friday, 8:30 a.m. to 5:00 p.m. After hours reconnection may be made at the City Police Department Monday through between 5:00pm – 9:00pm. An additional $150.00 will be charged for after hour’s reconnection. All payments and associated fees must be paid in full by money order or cashier’s check for after hour’s reconnection.

Application for Residential Utility Services

Service Address______Business Phone______

Responsible Party Name ______

Address______Phone#______

Have you ever had service with the City of Collinsville? YES______NO______If yes, when?______

SIGNATURE

SIGNATURE

DEPOSIT AMOUNT $______OWNER______RENTER______

Service AddressBusiness Phone

AddressPhone#

Have you ever had service with the City of Collinsville? YESNOIf yes, when?__

DEPOSIT AMOUNT $OWNERRENTER__