Utility Service Contract

I, the applicant hereby request to be supplied with gas and/or water. I agree to pay for such in accordance with the schedules of rates, rules, and regulations for the City of Graysville gas and Water Departments. Current charges are due each month on the 1st, late after the 15th, and up for interruption after the 25th.

In the event at any time in the future it is necessary to turn my delinquent account over to an attorney for collection, I agree to pay a reasonable attorney's fee and all necessary expenses, in addition to my balance, whether the attorney files suit or not, I also waive my right to claim personal property as exempt under the constitution and laws of the state of Alabama as to such debt or fee.

I further agree, (1) that the city shall retain title to all meters and other property furnished by it; (2) that I shall be responsible for the safe-keeping of all property of the city on the premises herein mentioned; (3) that I shall guarantee free right of ingress and egress by the city's employees to meters, regulators and other property if the city located on said premises; (4) that I will keep in repair all appliances and piping on said premises (other than meters and regulators maintained by the city), first notifying the city prior to having repairs made, and will report immediately to the city any leaks discovered; (5) that the city shall not be liable for damages because of interruption of the supply of gas or water or by reason of fires, accidents or any other cause due to or alleged to be due to the installation of the service or the escape or accumulation O gas or water, and I agree to indemnify the city against liability, loss or damage by reason thereof; (6) that the city shall not refund any payments made by applicant or property owner for service pipe from property line to meter, unless covered by separate agreements; and (7) that the city shall have the right to discontinue service without further notice in case of applicant's failure to comply with this agreement or any part thereof. I agree that any unpaid bills for gas or water service may be deducted from my meter deposits. A mediator may be designated by the City of Graysville Gas and Water Board to settle any discrepancies.

Attachment for signatures: Rental Agreement or Connection Waiver

Must Present Driver License or Passport and Social Security Card

PRINT Customer/Account Name*

Phone#*

SSN (Please enter N/A if this is for a business account)*

DL# (Please enter N/A if this is for a business account)*

EIN or TAX ID (Please enter N/A if this is for a personal account)

DOB*

PRINT Email address*

example@example.com

Paperless Bill?*

YN

PRINT Secondary Contact Person Name

Phone

Print Property/ Service Address:*

PRINT Property/Service Address: Street

Street Address Line 2

City, State, Zip+4

Print Billing Address if Different:

PRINT Billing Address if DIFFERENT: Street

Street Address Line 2

City, State, Zip+4

Do you:*

OwnRentManage *management companies must provide agreement

If renting you must provide Owner Contact Name (Enter N/A if you are not renting)

Email

example@example.com

Phone

Are you a prior customer of Graysville Gas and Water?*

YN

If so, please provide address

Employed:*

YN

Retired:*

YN

Self-employed:*

YN

Disability:*

YN

Social Security:*

YN

Employer Name*

Phone*

Signature*

Date*

Date

Driver License or Passport

Social Security Card

Ownership, P.O.A, Death Certification, Management agreement, etc

Utility Service Contract Residential and Commercial