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____.
















































































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