Commercial Water and Wastewater Application

Applicant Name*

First

Last

Business/Park Name*

Service Address*

Street Address City Postal / Zip Code

Mailing Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Driver's License No. / Tax ID*

State of DL or ID*

Office Phone*

Cell Phone*

Date of Birth*

day

/

month

/

year

Email*

Date Service to be Activated*

Confidentiality Please make one of the selections below*

I want personal information on my utility account (address, telephone, & Drivers License/Social Security) to be confidential, unless specifically exempted by state statute.

I do not want personal information on my utility account to be confidential, thus causing this information to be subject to open records provisions.

Waiver of Late Penalties Please make a selection if applicable

I am disabled as verified by the attached award letter from the social security administration.

I am over 60 years of age and request a waiver of late penalties over Texas house bill #670 also called the "Elderly Act"

Fees and Deposits (No Selection Required)

Fees and Deposits: $40.00 Service Initiation Fee with all applications-may be paid with the application or added on the first bill. Meter/Service Tampering: Fines and Fees are assessed by the City of Liberty Hill Municipal Code for anyone damaging, destroying, connecting, permitting the flow of unmetered water and tampering in anyway with City equipment.

Commercial Customers: $100.00 Depostit

General Information (No Selection Required)

The City shall have the right of access to the Customers' premises to set , read, remove, replace or repair meters. Service initiation requests received for Saturday, Sunday or Holidays will be initiated on the preceding business day.

Agreement Please select this box to agree on terms*

I certify that I am 18 years of age or older, that the above information is accurate, and that I will be responsible for payment of the entire bill upon termination of service. Additionally, if the City determines that I owe past due balances to the City, I will be responsible for payment of those balances and any associated fees before this application will be processed.

Signature*

Date*

Name (printed)*

First

Last

Word Verification