Tenant Application and Deposit for Water and Sewer Service

Tenant Application and Deposit for Water and Sewer Service
Name of Tenant*

First NameLast Name
Service / Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tenant Email*
example@example.com
Tenant Mobile Number
Please enter a valid phone number.
Tenant Home Number
Please enter a valid phone number.
Property Owner*

First NameLast Name
Property Rental Start Date*

MonthDayYear
Date
Length of Lease*
I agree to pay a $100 rental deposit fee to Broad Creek Public Service District to be held interest free by the District and intended to guarantee payment of bills for water and sewer service at the above mentioned “Service / Billing Address”. I understand that if at any time service is disconnected due to tenant damages to system or for nonpayment of fees, a $140 reconnect fee must be paid to reconnect to the District system. I further agree to provide the District with a forwarding address at the end of the lease term for purposes of final billing.

I understand that the due date of all bills is not later than fifteen (15) days from the billing date. An account is considered delinquent if not paid within thirty (30) days from the billing date. All delinquent accounts will be charged a late fee of 1.5% of past due balance. Failure to pay off the delinquent balance will result in service being discontinued.
Signature*

Clear
By signing my name above I understand and agree to each and all of the Terms and Conditions in this form. My electronic signature is legally binding.
Date*

MonthDayYear
Date
Should be Empty: