APPLICATION FOR WATER SERVICE

VILLAGE OF COLFAX 307 NORTH HARRISON ST P O BOX 380 COLFAX ILLINOIS 61728-0380 (309) 723-3261 1. DATE OF APPLICATION: __________________________________________ 2. NAME OF OWNER(S) OF PROPERTY: _______________________________ ___________________________________________________________________ OWNER'S ADDRESS: _____________________________________________ OWNER'S TELEPHONE NUMBER(S): ________________________________ 3. APPLICANT'S NAME: ______________________________________________ 3A. SPOUSE'S NAME: ______________________________________________ or 3B. NAME OF OTHER RESPONSIBLE ADULT(S) LIVING AT PROPERTY: ____________________________________________________________________ 4. APPLICANT'S PRESENT ADDRESS: ___________________________________ _____________________________________________________________________ 5. ADDRESS APPLICANT IS WANTING WATER/SEWER SERVICE AT: _____________________________________________________________________ (IF THERE IS A BALANCE DUE ON THE PREVIOUS ACCOUNT FROM THE PROPERTY YOU ARE MOVING INTO THE NEW SERVICE CANNOT BE STARTED UNTIL THAT BALANCE IS PAID IN FULL.) 6. APPLICANT'S TELEPHONE NUMBER(S): _________________________________ _______________________________________________________________________ 7. NAME AND ADDRESS OF APPLICANT'S EMPLOYER: _______________________________________________________________________ _______________________________________________________________________ 8. EMPLOYER'S TELEPHONE NUMBER(S): _______________________________________________________________________ 9. NAME AND ADDRESS OF SPOUSE'S EMPLOYER: __________________________ ________________________________________________________________________ 10. SPOUSE'S EMPLOYER'S TELEPHONE NUMBER(S): ________________________ ________________________________________________________________________ 11. NAME AND ADDRESS OF OTHER RESPONSIBLE ADULT'S EMPLOYER: ________________________________________________________________________ ________________________________________________________________________ 12. OTHER RESPONSIBLE ADULT'S EMPLOYER'S TELEPHONE NUMBER(S): ________________________________________________________________________ 13. DATE MOVING INTO/TAKING POSSESSION OF PROPERTY WHERE REQUESTING WATER SERVICE: _____________________________________________________ 14. FINAL READING AT RESIDENCE WHERE APPLICANT MOVING INTO: (VILLAGE CLERK'S USE ONLY) _________________________________________________________________________ 15. FINAL READING AT RESIDENCE WHERE APPLICANT MOVING OUT OF: (VILLAGE CLERK'S USE ONLY) _________________________________________________________________________ 16. WATER ON________; WATER OFF________; METER IN______; METER OUT______ (VILLAGE CLERK'S USE ONLY) 17. DATE WATER DEPOSIT PAID - DUE AT TIME OF APPLICATION: ________________ (FOR VILLAGE CLERK'S USE ONLY) SECTION 6:04(b) - WATER DEPOSIT $100.00 (DEPOSIT IS REFUNDED ONLY IN THE EVENT THAT YOU MOVE OUT OF TOWN AND THAT THE BILL CURRENT. IF THERE IS A BALANCE DUE THE BALANCE WILL BE DEDUCTED FROM YOUR DEPOSIT BEFORE ANY REFUND IS ISSUED. IF YOU MOVE FROM ONE RESIDENCE IN COLFAX TO ANOTHER RESIDENCE IN COLFAX, THE DEPOSIT CAN BE TRANSFERRED ONLY IF THERE IS NO BALANCE DUE ON YOUR ACCOUNT OTHERWISE, ANOTHER DEPOSIT IS REQUIRED AT THE NEW RESIDENCE UNTIL A FINAL BILL IS DONE FOR THE OLD RESIDENCE.) AS THE APPLICANT, SPOUSE, AND/OR OTHER RESPONSIBLE ADULT LIVING AT THE PROPERTY, I HEREBY AGREE TO THE FOLLOWING: TO ABIDE BY THE RULES OF SAID WATER AND SEWER ORDINANCES OF THE VILLAGE OF COLFAX. ________________________________________ APPLICANT'S SIGNATURE _________________________________________ SPOUSE'S SIGNATURE OTHER RESPONSIBLE ADULT'S SIGNATURE ATTEST: _____________________________________ VILLAGE CLERK DATED THIS _______ DAY OF ___________________________, 20____. '