HomeMy WebLinkAboutTenant_App_Service_FormSOUTH BEND MUNICIPAL UTILITIES
Tenant Application for Service
125. W Colfax, South Bend, IN 46601
Phone (574)235-9236 Fax (574)235-5645
__________________________________________________________________________________________
TO BE COMPLETED IN CONJUNCTION WITH OWNER AUTHORIZATION OF SERVICE FORM
Date: _______________ SERVICE ADDRESS: _______________________________________________
TENANT INFORMATION:
Name of Tenant: _________________________________________________________________________
Primary Phone #: ___________ (cell/home)
Name of Legal Agent of the Business if property is in the name of a business:
____________________________________________________ Primary Phone #: ___________ (cell/home)
Social Security #: ______-____-______ Federal Tax ID: _____-______________
Identification #: ________________ Type of ID: ____Driver’s License ____State ID ____Passport
Date of Lease: _________________ Date to start service: _______________ a.m.___ or p.m.___
Mailing address (if different than service address): ________________________________________________
_________________________________________________________________________________________
Employer: _________________________________________________ Phone # _______________________
Emergency Contact: _________________________________________ Phone # _______________________
Email address: ______________________________________________
OWNER INFORMATION:
Name of Property Owner: ___________________________________________________________________
Mailing Address of Owner: ___________________________________________________________________
Phone #: __________________
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By signing this form, I acknowledge as the tenant, the following:
➢ My 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.
➢ I must inform South Bend Municipal Utilities of termination date, upon vacating the property.
➢ I must inform South Bend Municipal Utilities of any updated contact information.
➢ I am responsible for any service charges and miscellaneous charges while residing in this premise.
➢ If there is an interruption of water services for any reason, the South Bend Municipal Utilities has fully
explained, and I understand the potential risks and damages that may result from any open faucet,
toilet or leaking water pipe located inside or outside the property. I am therefore encouraged to have
someone over the age of 18 present when water service is restored.
Full Signature of Applicant: ______________________________________________ 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: