The Service Fee($30 Inside/$40 Outside) Is Non-Refundable

The service fee($30 inside/$40 outside) is non-refundable

Rental/Lease Agreement or Proof of Ownership is required

Date ______

Name ______

Service Address ______

Mailing Address ______City, State, Zip Code ______

Home Phone (______) ______-______Work Phone (______) ______-______

Residential ______or Commercial ______(Check One) Owner ______or Renter ______(Check One)

Date of Birth _____/_____/_____ (mm/dd/yy)Social Security Number ______-______-______

Race W: _____ B: _____ H: _____ Other: _____

Driver License Number ______State of Issue ______

Adult Co-Habitant ______Number of people in the Household ______

E-Mail Address ______

Employer ______

Employer Address ______

Have you ever had Hartsville Utility service before? Yes:_____ No:_____

If so, enter last service address ______

If renting or leasing provide the name and telephone number of the property owner and/or rental agent in the area provided below.

Owner/Rental Agent name: ______

Owner/Agent telephone number (______) ______-______

DO NOT WRITE BELOW THIS LINE - ADMINISTRATIVE USE ONLY

______

Connection Date ______Account # ______

If this property is a rental property outside of the corporate limits of the city of Hartsville, is there an

Annexation agreement on file? ______

Copy of rental agreement on file? ______

Copy of driver's license on file? ______

Service Fee Paid: Inside $______Outside $______Turn Over 

Thisagreement,whensignedbytheConsumerandbyandauthorizedrepresentativeoftheCityofHartsville,shallbecomeacontract underwhichtheCityofHartsville agrees to furnishUtilityServicestotheindividualConsumer,andtheConsumeragrees toreceiveandpayforsaid serviceinaccordancewith theRate Schedule andtheServiceRegulations of theCityofHartsvilleon fileinthe officeof theCityofHartsville,and as thesamemaybemodifiedfrom time totime,whichRate SchedulesandService Regulations are hereby madeapartof this contractaseffectuallyasif fullyset forthherein.

TheConsumer mustmaintainasafepassagewayformeteraccessbytheCityofHartsville.Additionally, theConsumerhas theresponsibilityto keepthe meter freefrom obstructionsandtorestrainpetsor byremovingobstacles thattheCityofHartsville mightencounterat thatproperty.Failure of theConsumertoprovidefreeaccessmayresultin the termination ofutilityserviceuntil suitableaccessis provided.Billsmaybe renderedon thebasisofestimatedmeter readingswhenevertheCityofHartsvilleis unabletoobtaina meter readingbecause ofinaccessibilitytotheConsumer'spremises,orfor other reasons.Inanycase, consumptionshallbeestimatedbased upon the bestinformation available.

TheConsumershallnotinterferewith, oraltertheCityofHartsville's meters, seals,or otherproperty,or permit the sametobedonebyother than theCityofHartsville'sauthorized agentor employee.Damagecausedor permittedbytheConsumer tosaidpropertyshallbepaidfor bytheConsumer. Whenunauthorized use ofutilityservicesisdiscovered, the CityofHartsvillemaydiscontinueserviceandtheConsumershall berequiredtopayfor the estimatedunauthorizedusage, the costof investigation, reconnection,andanyother lossresultingfromthechanging,tampering,or interfering withthemeter, before serviceis restored.

TheCitywillmakeallreasonableeffortstoprovidecontinuousanduninterruptedutilityservice, but cannotbeliablefor lossor damage(direct,consequential orotherwise) caused byanfailureto supplyelectricity,water- sewer,orbyaninterruption, ifitisduetoanycausebeyondthereasonablecontrolof the City.The Citycannot beheld accountable for actsofGod.

Unless otherwiseprovided, this agreement shall continuefrommonthtomonththereafter.Thesamemaybeterminatedbyeither partyafterexpirationofanyfixedperiodinitiallyspecified,upononeworking daynoticetotheother. Itis further agreedthattheCityofHartsvillereservestheright todiscontinue servicesif theConsumerbreaches this serviceagreement. If the serviceis disconnectedforcause,theConsumer agreestopayall outstandingbillsand anapplicablereconnection fee forservice toberestored.TheConsumer understandsthat theinformationfurnishedonthis applicationwillbe verifiedand ifdeterminedinaccurate, willresultinthe termination of servicewithoutpriornotice.TheConsumer acknowledgesthat theCityofHartsvilleshall havetherighttosharetheConsumer’s customeraccountinformation andother informationwithotherutilityproviders.

TheapplicantunderstandsthattheCitymusttakeactionandexpendfundstocomplywiththisrequest for service. Bysigning theapplication,theapplicant signifies thatheor she has theauthoritytorequestutilityserviceat thelocationidentified above.

TheConsumer whosignsfor serviceagreestoberesponsiblefor receiptandpaymentofbillsfor theseservices.Failure toreceiveamonthlybilldoesnot relieveConsumerof paymentresponsibility.Itis furtherunderstoodthat shouldthenon-refundable service fee bedeterminedinsufficient, theConsumerwillmakeandadditionalnon-refundable service fee uponrequest fromtheCityofHartsville not toexceed the twohighestmonths’utility bills.

Iattest that theinformationgivenon this contractis trueandaccurateto the bestofmyknowledge.

ADDENDUM

BysigningthisapplicationforWater,StormWater,Sanitation,Sewer and Yard DebriswiththeCityofHartsville;theapplicantagreestopayallcostsof collectionoftheapplicant’sunpaidbills.TheCityofHartsvillehastherightpursuanttotheSouthCarolinaSetoffDebtCollectionActtocollect anysumdueandowedbytheapplicantthroughoffsetoftheapplicant’sstateincometaxrefund.

IfTheCityofHartsvillechoosestopursuedebtsowedbytheapplicantthroughtheSetoffDebtCollectionAct,theapplicantagreestopayallfees andcostsincurredthroughthesetoffprocess,includingfeeschargedbytheDepartmentofRevenue,theSouthCarolina AssociationofCounties, theMunicipalAssociationofSouthCarolina,and/orTheCityofHartsville.If TheCityofHartsvillechoosestopursuedebtsinamannerotherthan setoff,theapplicantagreestopaythecostsandfeesassociatedwiththeselectedmanneraswell.

By ______X ______

Customer Service RepresentativeApplicant’s Signature

Date______Date______