Water-Sewer Application

Applicant Name*

First

Last

Service Address*

Street Address City Postal / Zip Code

Driver's License No. / Tax ID*

State of DL or ID*

Date of Birth*

day

/

month

/

year

Email*

Date Service to be Activated*

Home Phone*

Cell Phone*

Co Applicant Name

First

Last

Mailing Address*

Street Address City Postal / Zip Code

Confidentiality: House Bill 872, in effect as of September 1, 2021, prohibits a government-operated utility from disclosing a customer's personal information (defined as an individual's address, telephone number, social security number) as well as information relating to the volume or units of utility usage or the amounts billed to or collected from the customer unless the customer requests that the information be disclosed. Therefore, please indicate below if you desire for this information to be disclosed to the public. Please make one of the selections below

I want my personal information on my utility account to be disclosed to the public, 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: $30.00 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.

Residential Customers: $100.00 Deposit

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 old 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*

Word Verification