HomeMy WebLinkAbout5.4.23- Updated Owner_Authorization_Service- v1.1SOUTH BEND MUNICIPAL UTILITIES
Owner Authorization of Service Form
125. W Colfax, South Bend, IN 46601
Phone (574)235-9236 Fax (574)235-5645
__________________________________________________________________________________________
TO BE COMPLETED IN CONJUNCTION WITH TENANT APPLICATION FOR SERVICE
Date: _______________ SERVICE ADDRESS: _______________________________________________
Number of units: _________________
OWNER INFORMATION:
Name of Property Owner: ___________________________________________________________________
Name of Trustee or Legal Agent of the Business if property is in the name of a trust or business:
______________________________________________________
Cell Phone #: ___________________ Home Phone #: __________________
Social Security #: ______-____-______ Federal Tax ID: _____-______________
Identification #: ________________ Type of ID: ____Driver’s License ____State ID ____Passport
Mailing address of Owner: ________________________________________________
________________________________________________
Email address: ______________________________________________
TENANT INFORMATION:
Name(s) of Tenant(s): _______________________________________________________________________
Cell Phone #: ___________________ Home Phone #: ________________
Name of Legal Agent of the Business if property is in the name of a business: ___________________________
Date of Lease: _________________
Continued on Back
By signing this form, I acknowledge as the property owner, the following:
Service will not be started until both the Owner Authorization of Service and Tenant Application for Service forms, along with the paid deposit (if applicable), have been received by
the South Bend Municipal Utilities.
The Utilities account will be in my tenant’s name; I am ultimately responsible for payment of all Utilities charges other than Water Charges, Refuse Charges and Miscellaneous Fees at
this location and the City may file a lien against my property for unpaid Sewer and Storm Water charges, pursuant to Indiana Code 36-9-23-32, 8-1.5-5-29, and 8-1.5-5-30.
I waive the right to have services disconnected once the account is placed in the Tenants name.
By putting water services in the name of my tenant, I authorize them to make decisions regarding turning services off or on. I understand that water could leak from any open faucet,
toilet or water pipe located inside or outside the property should water need to be restored.
Per the South Bend Municipal Utilities Rules and Regulations, in the case where a tenant terminates services or if account is shut off for non-payment, the utility reserves the right
to revert the account to the homeowner’s name once the account has been final billed. The landlord account is a place holder until a new tenant moves in. The account will only be billed
for water insurance, sewer insurance, stormwater and clean air. Though the water will be left on, water and trash services will not be available. If usage is recorded, all services
will be activated and the account will be billed in full each month. This may include a deposit and service fees.
Due to the nature of the Water and Sewer insurance programs, per the South Bend Municipal Utilities Rules and Regulations, if unpaid for four consecutive months discontinuation of coverage
will occur and will not cover damages.
Unauthorized Usage Fees may be assessed to the Owner if new Tenant Application for Service/Owner Authorization of Service forms are not provided to South Bend Municipal Utilities and
usage should occur.
I swear and affirm under the penalties for perjury that by signing my name to this form below, that I am attesting to the fact that I am the lawful owner of the property/home described
in this form. The information that is entered on this form is correct and I understand that making a false statement on this form may constitute the crime of perjury.
Full Signature of Property Owner: ________________________________________ Date: ________________
_________________________________________________________________________________________
Office Use Only:
Account #: ____________-___________ Inside: ____ Outside: ____ Clay: ____
Cycle/Route: ____________ Type of Service: ___Sewer ___Water ___Irrigation ___Storm Water
Deposit: $__________ Meter Size: ______ Water ______ Irrigation
Service Initiation Fee: $__________ Name of CSR: ________________________________________
Notes: