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Residential Utility Application 2019

2. 

4. Note:
   All water users will make a deposit to the City of Elgin prior to obtaining service. The standard deposit fee will be $200 plus a $25 application fee.

   All water users will make a deposit to the City of Elgin prior to obtaining service. The standard deposit fee will be $200 plus a $25 application fee.

6. 

8. Service Start Date*
   Service Start Date

10. New Service Address*

    Elgin, TX 78621

12. Mailing Address

14. City

15. State

16. Zip Code

20. CUSTOMER INFORMATION

22. Primary Name (printed on the bill)*

24. Driver's License / ID Number (ONLY 3 last digits)*

25. Date of Birth*
    Date of Birth

27. Home Phone Number*

28. Work Phone Number

30. Cell Phone Number

31. Alternative Phone Number

33. Secondary Name (not printed on the bill):

35. Driver's License / ID Number (ONLY 3 last digits)

36. Date of Birth
    Date of Birth

38. Home Phone Number

39. Work Phone Number

41. Cell Phone Number

42. Alternative Phone Number

46. PREFERRED BILLING INFORMATION

48. Preferred Billing Method*

    1. PAPER BILL – U.S. MAIL
    2. PAPERLESS BILL – EMAIL

49. Primary Email

53. Information Confidentiality

    Please check the box to elect to have your information remain confidential. Utility customers have the right to request confidentiality of personal information. Personal information is defined as “an individual social security number, address or telephone number”. Typically, these things have been available routinely through an Open Records Request. All other information on your account is still subject to the terms of the Open Records Act. Further, this information is still available to other utility suppliers, law enforcement agencies, government officials and consumer reporting agencies.

57. Initial*

    Customers are responsible for the timely payment of their Utility Bill whether the bill is received or not. Utility bills are mailed to customers every month and are due on the 15th of each month. If you do not receive your utility bill, please contact the Utility Billing Department as soon as possible.

59. Initial*

    Customers are responsible for reviewing the accuracy of their Utility Bill. If you find an error, please contact the Utility Billing Department as soon as possible.

61. Initial*

    If not paid by the due date, a penalty of 10% of the unpaid balance is applied to the account. Full payment including penalty charge is due no later than the 25th of the month.

63. Initial*

    Service will be disconnected if full payment is not received on or before the 25th of the month and will include a fee of $75.00. This is an administrative fee and will be charged whether your service is disconnected or not.

65. Initial*

    To restore service the past due balance and all penalties must be paid. After payment is received, service will be restored by the end of business day.

67. Initial*

    Services restored AFTER HOURS will be charged an additional $50.00 after hours connection fee.

69. Initial*

    It is unlawful for any person or property owner to reconnect or attempt to reconnect service and is punishable by fine up to $100.00. If meters are found to be tampered with (locks cut, etc.) fees will be charged to the account.

71. Initial*

    Please keep meter box areas easily accessible to City Staff and free of debris/growth.

73. 

75. Visit City of Elgin Website

77. I certify that all the above information is true and correct to the best of my knowledge. Also, I acknowledge that any previous City Of Elgin Utility Account balances owed by me or authorized person listed above will be due at the time of service.

79. Payment
    Payment accepted in the form of: cash, check, money order, Visa, MasterCard or Discover only. Make check or money order payable to the City of Elgin Utilities. Online payment is available once account is established by the Utility Billing Department.

    Payment accepted in the form of: cash, check, money order, Visa, MasterCard or Discover only. Make check or money order payable to the City of Elgin Utilities. Online payment is available once account is established by the Utility Billing Department.

81. Signature*

82. Date*
    Date

86. Attach Documents

88. Please provide a copy of a legal lease agreement listing all occupants over the age of 18 living in the home. OR a copy of the Settlement Page if you have purchased the property. A tax statement will also be accepted for property owners.*

    Attach file here

90. Please read carefully:*

    1. I acknowledge that my new account won't be created until I send a copy of my Driver's License / ID to utilitybilling@ci.elgin.tx.us.

94. For office use only

96. Date of Connection
    Date of Connection

97. Account Number

98. Initials

100. 

Leave This Blank:


101. 1. Receive an email copy of this form.
102. Email address

     This field is not part of the form submission.

103. Submit

* indicates a required field