HomeMy WebLinkAboutTenant App5.9.2025Tenant Application for Service
South Bend Municipal Utilities
125 W. Colfax Ave, South Bend IN 46601
Phone: 574-233-0311 Email: 311@southbendin.gov
TO BE COMPLETED IN CONJUNCTION WITH OWNER AUTHORIZATION OF SERVICE FORM
Date: ____________ Service Address: ________________________________
TENANT INFORMATION
Name of Tenant:
__________________________________________________________
Primary Phone Number:
__________________________________________________________
If property is in the name of a business, name of legal agent of the business:
__________________________________________________________
Social Security Number: _____-____-___ Federal Tax ID (if a business): ____________
Type of ID (circle one): Driver’s License State ID Passport
Identification Number: ____________________________________________
Date of birth: (MM/DD/YYYY): ________________________________________
Date to start service: _____________ (circle one: AM PM )
Mailing address (if different from service address):
__________________________________________________________
Email address: _________________________________________________
Are you new to the City of South Bend? Yes No
Do you currently have other water accounts with the City of South Bend?
Yes No
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If you have another water account, what is the address for the account?
Service Address: _________________________________________
_________________________________________
Are you planning to leave this service on, or do we need to schedule termination?
Yes, leave on No, schedule termination Date for termination: __________
OWNER INFORMATION
Name of Property Owner:
_______________________________________________________
Mailing Address of Owner:
_______________________________________________________
_______________________________________________________
Phone Number:
_______________________________________________________
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 at this
property.
• 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 liaison: ___________