Section
NAME ID NUMBER
SPOUSE ID NUMBER
ADDRESS TELEPHONE NO.
EMPLOYER ADDRESS
SPOUSE EMPLOYER ADDRESS
PREVIOUS ADDRESS LANDLORD'S NAME
Have you ever had utility service in Monticello before?
Have you ever had utility service under another name? If so, what name?
Signature of Applicant
Landlord's Verification
I verify that the applicant is renting the property located at the following address:
I am aware of the Indiana law which places responsibility on the land owner for uncollected sewer fees.
I agree to notify the Utility Office in the event the tenant becomes delinquent in their rent agreement with the land owner or moves out before notification to the Utility Office.
I will request my tenant provide a signed form from the Utility Office verifying charges are paid or current.
Signature of Landlord:
Note: Indiana Code 36-9-23 requires the Clerk Treasurer to place a lien on real property for sewer utility fees unpaid.
(Ord. 01-02, passed 5-7-01)
Agreement
Customer Name Date
Address Account
City Phone
Payment Schedule
Total Amount to be Paid Under This Agreement $
Initial Payment by Customer $
Balance Due to be Paid per Payment Schedule $
Payment Schedule
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
Date Due Amount $
The customer also agrees to pay all undisputed future service bills as they become due.
If the customer does not fulfill the terms of this Agreement, the Agreement will be voided and the total unpaid past due amount shall become due.
Failure to comply with the conditions of this extension will result in disconnection without further notice.
Customer Signature Monticello Utilities Rep.
(Ord. 01-02, passed 5-7-01)