Stonewall Ranch OR Grand Oaks of LH Wastewater Service Application

Applicant Name*

First

Last

Co Applicant Name

First

Last

Service Address*

Street Address City Postal / Zip Code

Mailing Address*

Street Address City Postal / Zip Code

Driver's License No. / Tax ID*

State of DL or ID*

Home Phone*

Cell Phone*

Email*

Date of Birth*

day

/

month

/

year

Date Service to be Activated*

Confidentiality (Please make one of the selections below)*

I DO want personal information on my utility account (ie: address, telephone number, and driver's license number) 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: $40.00 (out-of-city residents) OR $30.00 (In-city residents) Service Initiation Fee with all applications-may be paid in person 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.

Deposit: $100 (refundable upon disconnection - with no balance present) Deposit can be waived with presentation of letter of credit (from previous utility) within 3 days of submission of application.

General Information (No Selection Required)

The City shall have the right of access to the resident's 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 any past due balances, I will be responsible for payment of those balances and any associated fees before this application will be processed.

Signature*

Date*

Word Verification