HomeMy WebLinkAboutOwner_Authorization_Service- 9.16.23SOUTH 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: ______________________________________________
I would like to receive a copy of the regular bill and the delinquency bill: _______ Yes _______No
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, 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, storm water and clean air. Though
the water will be left on, water and trash services will not be available. The owner will need to set up
a new account in their name and pay a deposit (if applicable) to have all services available for use.
➢ 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 that I understand that making 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: ________________________________________