Kingston Water Department Forms

Form Type:*

DATE CONNECTED:

Date

ACCOUNT #:*

AMOUNT PAID OR BILLED:

DATE FINALLED:

Date

DATE CLOSED:

Date

NAME:*

First NameLast Name

BUSINESS NAME (IF APPLICABLE):

SERVICE ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

MAILING ADDRESS: (IF DIFFERENT)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

OWNERSHIP:*

OWNERLANDLORDRENTER

LEASE DATE

Date

PHONE #1:*

PHONE #2:*

EMAIL:*

example@example.com

DRIVERS LICENSE NUMBER OR ID NUMBER:*

SSN#*

DATE OF BIRTH:*

Date

STATE:*

METER:

TRANSPONDER #:

SERVICES:

Would you want to be contacted by email or text concerning your account or water issues?*

EmailTextNeither

Would you like to receive your bills by email instead of mail?*

YesNo

Is there any medical reason that service cannot be interrupted?*

YesNo

Written verification from a medical doctor is required before meter can be labeled as non-cut-off. The water bill is still required to be paid in full, but notification will be made prior to disconnect.

RACE ETHNICITY:

HISPANIC/LATINO

YesNo

The undersigned hereby makes application for service at the above address and agrees to pay for said service as measured by the System's meters, according to the System's Standard Rules and Regulations and further agrees, that if bill becomes delinquent and must be sent to Collection Agency, will be responsible for all costs incurred for the Collection Services. The applicant agrees to be responsible for all water consumed upon the premises from the date of installation and to permit authorized agents of the System free access to the premises of the consumer for the purpose of inspecting, reading, examining, repairing, or removing meters or other property belonging to the System. The applicant shall provide the necessary space on or in its premises for the location, safe keeping and protection of pipe, devices, meters, and meter boxes. The applicant shall see that at all times the meter and meter box be accessible to the meter readers or other employees of the Kingston Water Department (This includes landscaping, fences, and parked vehicles).

**FAILURE TO RECEIVE BILL DOES NOT RELIEVE CONSUMER OF PAYMENT AND PENALTY**

The applicant is strictly forbidden to interfere with the meters or other appliances of the Utility.

The applicant agrees to pay a minimum cost of $200.00 for repair or replacement, if meter is tampered with, broken, or disabled in anyway.

The applicant agrees to notify the Kingston Water Department in writing when they desire services to be discontinued and agrees to pay for all services for a reasonable time after such notice, in order to permit KWD to read or remove meter and render bill.

Signature*

APPLICANT ACKNOWLEDGES RECEIPT OF LEAK PROTECTION POLICY INFORMATION*

APPLICANT ACKNOWLEDGES RECEIPT OF INFORMATION REGARDING PAYMENTS, PENALTIES, DISCONNECT FOR NON-PAYMENT AND FEES ASSOCIATED FOR RECONNECT*

APPLICANT ACKNOWLEDGES THAT ACCOUNT OPENED AFTER READ DATE WILL BE ISSUED A MINIMUM BILL APPROXIMATELY*

POLICIES AND PROCEDURES LINK- https://water.kingstontn.gov/water-home/water-sewer-policies-procedures /Revised -08.28.23

Name:*

First NameLast Name

Phone Number:*

Please enter a valid phone number.

Email:*

example@example.com

Today's Date:*

Date

Account Number:*

Property Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Disconnect:*

Date

Forwarding Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date Connected:*

Date

Water Department Forms

New Water Application

Voluntary Information for Federal Grant

Water Disconnect Application: