| CITY OF ANNA | ACCOUNT NO: ________________________ |
| 103 Market Street | Attached Identification: (For Office Use Only) |
| Anna, Illinois 62906 | Photo ID copy _______ |
| Tel: 618-833-8528 | Dep.CR copy ________ |
| Fax: 618-833-3933 | Current BIlls _________ |
| Delq.Listing _________ | |
| NAME:________________________________________________ |
| SERVICE ADDRESS: ____________________________________ |
| ____________________________________ |
| MAILING ADDRESS:____________________________________ |
| ____________________________________ |
| DAYTIME PHONE:______________________________ |
| OWN__________ RENT_________ CONTRACT FOR DEED_________ |
| PROPERTY OWNER: ___________________________________ |
| MAILING ADDRESS: ___________________________________ |
| OWNER PHONE #:_____________________________________ |
| HAVE YOU HAD UTILITIES IN YOUR NAME BEFORE IN ANNA? YES_______ NO_______ |
| IF SO, WHAT ADDRESS? ____________________________________ |
| DATES OF SERVICE: ____________________________________ |
| UTILITIES REQUESTED: GAS_______ WATER_______ SEWER_______ TRASH_______ |
| CUSTOMER DEPOSITS RECEIVED: GAS $175.00 WATER $75.00 |
| CASH OR MONEY ORDER ONLY |
| UTILITY
TURN-ON FEES: YOU ARE HEREBY NOTIFIED that if the requested utilities are
off at this time, a $10.00 charge will be incurred on the initial utility
bill for each utility which is turned on ($10.00 for gas and $10.00 for
water). BILLING AND PAYMENT INFORMATION: Your utility bill will be printed on or about the 4th of the month and will be due on or about the 20th of each month. Should you not receive a bill, you may call or come to the Anna City Hall to determine the balance due on the account. FAILURE TO RECEIVE your utility bill DOES NOT relieve the customer of their obligation to pay the amount due, PLUS any late charge incurred. |
| AGREEMENT AND ACCEPTANCE OF CONDITIONS FOR SERVICE (RENTERS): |
| The undersigned, hereby requests to be supplied with utility services by the City of Anna, Illinois, and hereby acknowledges that he/she has been presented and received a notice concerning buried gas piping within the city. By affixing my signature below, I the undersigned, hereby agree: 1) To pay timely in accordance with the schedule of rates and adopted policies of the City, for utilities supplied for the premises subscribed by me, until such time as I request that said utilities be terminated, 2) should I fail to comply with this Agreement, the City may terminate my utilities at the premises without further notice, other than that notice prescribed in Section 98.7 of the adopted utility policies of the City; and 3) to pay all reasonable legal and attorney's fees, costs and expenses, incurred by the City as a result of my failure to comply. |
| DATE: _____________________ SIGNED: _________________________________________ |
| AGREEMENT AND ACCEPTANCE OF CONDITIONS FOR SERVICE (OWNERS): |
| The undersigned, as legal owner of the above-identified property, hereby acknowledge that I have read and fully understand this application and the conditions upon which utility service may be extended to my property. I further acknowledge and agree that as the owner of said property, I will receive delinquency notices, as provided by the policies of the City, which will advise and inform me of unpaid utility bills and any prospective dates of termination of utility services, on and for any rental property which I own within the city's utility service area. I further acknowledge, understand and agree that as the owner of said property, it is my ultimate responsibility to ensure that any and all balances due and owing City have been paid in full, prior to releasing any security deposits to my renter/tenant(s). Lastly, I further acknowledge and agree that future utility service will be denied to the above described property until and after delinquent and unpaid utility bills, late charges, penalties and/or fees have been paid in full, and that my property shall be subject to liens and any and all other legal collection procedures utilized within the State of Illinois. |
| DATE: _____________________ SIGNED: __________________________________________ |