Application for Utility Service
Utility Application
240 East Gammon Road Vineyard, UT 84058 801-226-1929 [email protected]
Complete this form and return it, along with proof of home ownership (closing or title documents) to the town. A nonrefundable $20 Utility Application Fee will be included on your first utility statement. This fee can be waived by signing up for Direct Pay at the time of application. UNLESS OTHERWISE SPECIFIED, ALL MONTHLY UTILITY BILLS WILL BE SENT TO THE APPLICANT’S EMAIL ADDRESS. _________________________________________________________ Applicant’s Name
__________________________________ Spouse
___________________________________________________________________________________________________ Service Address ___________________________________________________________________________________________________________________________
Mailing Address (If different from service address) ______________________ Primary Phone _________________________ Social Security Number
______________________ Secondary Phone
_________________________________________ Email Address
___________________________ Driver’s License Number
______________________________________________________ Employer Name
__________________________ Birth Date __________________________________ Employer Phone ___________________________________________
____________________________________________________________________
Emergency Contact
Emergency Contact Phone
I hereby apply for the following services (please check each service applying for): Water Sewer Recycling Garbage Garbage Cans: (select from the dropdown) Current # of Cans: Desired # of Cans:
Recycling Cans: (select from the dropdown) Current # of Cans: Desired # of Cans:
The town shall make the requested connection from its water and sewer main to the water meter and up to the property line or to the meter if the meter is installed within the property. The water and sewer connection so made by the Town, including the meter, shall remain the property of the Town, and the Town shall have access thereto at all times. Applicant will be bound by all rules, regulations, resolutions and ordinances enacted now or hereafter by the Town applicable to the Town water and sewer system. Applicant agrees to pay all charges for water and sewer service as adjusted from time to time by the Town Council until such time as the service is disconnected. In the event of a failure to pay utility charges within the due dates fixed by the Town Council or failure of the occupant to conform to the ordinances and regulations established by the Town Council the Town shall have the right to discontinue service pursuant to written notice until all delinquencies and any reconnection fees are paid in full. The Town shall have the right to institute collection proceedings by all means available, including suit in a court of property jurisdiction. The applicant agrees to pay all costs of collection including court costs and attorney’s fees. ______________________________________________ Applicant Signature ________________________________________________ Date
Closing Date: Account #: Meter #: Office Tech:
FOR OFFICE USE ONLY
Date:
Recycling Opt-Out
240 East Gammon Road Vineyard, UT 84058 801-226-1929 [email protected]
If you do NOT want to participate in the Town’s recycling program, please fill out all sections of this form. ___________________________________________________________________________________________________ Applicant’s Name ___________________________________________________________________________________________________ Service Address ___________________________________________________________________________________________________________________________
Mailing Address (If different from service address) ______________________ Primary Phone
______________________ Secondary Phone
_________________________________________ Email Address
I understand that by signing below, I am choosing NOT to participate in the curbside recycling program offered by Vineyard. I can opt-in at any time by contacting the Town. I affirm that the information provided on this form is true and correct to the best of my knowledge. ____________________________________________________________________________
Applicant Signature
Account #: Office Tech: Date:
FOR OFFICE USE ONLY
______________________
Date
Direct Pay Authorization
240 East Gammon Road Vineyard, UT 84058 801-226-1929 [email protected]
The direct pay program is designed to make paying your utility bill easy, convenient, and to save you time and money. The direct pay program will automatically withraw your utility payment directly from your financial institution each month. As an incentive for participation in this program, Vineyard Town will waive the $20.00 utility application fee if you sign up. PLEASE ATTACH A VOIDED CHECK TO THIS FORM. Things to know about Direct Pay: • On your utility bill the following message will appear: ‘Automatic Payor’. This is your notification that direct pay has been activated and the next payment will be automatically deducted from your checking or savings account. (If you are a current customer and you are switching to direct pay after th 15th of the month, you wil need to manually pay your current payment.) • You must keep this payment arrangement in place for no less than 6 months from the date you sign this agreement or your account will be charged the $20.00 utility application fee. • You are authorizing the Town of Vineyard to debit your checking or savings account for all monthly charges for utility services. • If there are NOT sufficient funds in your checking or savings account to cover your bill, your utility account will be charged $10.00 for Non-Sufficient Funds (NSF). • Promptly notify the Town of Vineyard of any change to your checking or savings account. If a change occurs, it is your resposibility to provide the Town of Vineyard with the updated account information. • Two refused electronic fund transfers may cancel this agreement at the sole option of the Town of Vineyard. ACCOUNT INFORMATION ______________________________________________ Name of Financial Institution ______________________________________________ Bank Routing Number (9 digits) ______________________________________________ Bank Account Number
Checking Account
Savings Account
Use this image to determine which number on the check is the bank’s routing number and which is your account number.
I hereby authorize the Town of Vineyard to initiate automatic withdrawals from the financial institution indicated above for the purpose of paying my monthly utility bill. I understand that an automatic payment will be deducted from my account on the 20th of each month or the following business day if the 20th is on a weekend or holiday. I understand that I will be responsible to pay a non-sufficient funds fee as specified by the Town for any automatic debit that is returned due to insufficient funds. This authority is to remain in full force and effect until either (1) I revoke it by giving notice to the Town of Vineyard, by letter or by phone; (2) it is cancelled by the Town of Vineyard under the conditions stated above; or (3) upon termination of my service with the Town of Vineyard. I have read and agree to the terms and conditions outlined above. ________________________________________ Applicant Name (Please Print)
____________________ Utility Account Number
________________________________________ Applicant Signature
____________________ Date
FOR OFFICE USE ONLY Office Tech: Date:
240 East Gammon Road Vineyard, UT 84058 801-226-1929 [email protected]
Complete this form and return it, along with proof of home ownership (closing or title documents) to the town. A nonrefundable $20 Utility Application Fee will be included on your first utility statement. This fee can be waived by signing up for Direct Pay at the time of application. UNLESS OTHERWISE SPECIFIED, ALL MONTHLY UTILITY BILLS WILL BE SENT TO THE APPLICANT’S EMAIL ADDRESS. _________________________________________________________ Applicant’s Name
__________________________________ Spouse
___________________________________________________________________________________________________ Service Address ___________________________________________________________________________________________________________________________
Mailing Address (If different from service address) ______________________ Primary Phone _________________________ Social Security Number
______________________ Secondary Phone
_________________________________________ Email Address
___________________________ Driver’s License Number
______________________________________________________ Employer Name
__________________________ Birth Date __________________________________ Employer Phone ___________________________________________
____________________________________________________________________
Emergency Contact
Emergency Contact Phone
I hereby apply for the following services (please check each service applying for): Water Sewer Recycling Garbage Garbage Cans: (select from the dropdown) Current # of Cans: Desired # of Cans:
Recycling Cans: (select from the dropdown) Current # of Cans: Desired # of Cans:
The town shall make the requested connection from its water and sewer main to the water meter and up to the property line or to the meter if the meter is installed within the property. The water and sewer connection so made by the Town, including the meter, shall remain the property of the Town, and the Town shall have access thereto at all times. Applicant will be bound by all rules, regulations, resolutions and ordinances enacted now or hereafter by the Town applicable to the Town water and sewer system. Applicant agrees to pay all charges for water and sewer service as adjusted from time to time by the Town Council until such time as the service is disconnected. In the event of a failure to pay utility charges within the due dates fixed by the Town Council or failure of the occupant to conform to the ordinances and regulations established by the Town Council the Town shall have the right to discontinue service pursuant to written notice until all delinquencies and any reconnection fees are paid in full. The Town shall have the right to institute collection proceedings by all means available, including suit in a court of property jurisdiction. The applicant agrees to pay all costs of collection including court costs and attorney’s fees. ______________________________________________ Applicant Signature ________________________________________________ Date
Closing Date: Account #: Meter #: Office Tech:
FOR OFFICE USE ONLY
Date:
Recycling Opt-Out
240 East Gammon Road Vineyard, UT 84058 801-226-1929 [email protected]
If you do NOT want to participate in the Town’s recycling program, please fill out all sections of this form. ___________________________________________________________________________________________________ Applicant’s Name ___________________________________________________________________________________________________ Service Address ___________________________________________________________________________________________________________________________
Mailing Address (If different from service address) ______________________ Primary Phone
______________________ Secondary Phone
_________________________________________ Email Address
I understand that by signing below, I am choosing NOT to participate in the curbside recycling program offered by Vineyard. I can opt-in at any time by contacting the Town. I affirm that the information provided on this form is true and correct to the best of my knowledge. ____________________________________________________________________________
Applicant Signature
Account #: Office Tech: Date:
FOR OFFICE USE ONLY
______________________
Date
Direct Pay Authorization
240 East Gammon Road Vineyard, UT 84058 801-226-1929 [email protected]
The direct pay program is designed to make paying your utility bill easy, convenient, and to save you time and money. The direct pay program will automatically withraw your utility payment directly from your financial institution each month. As an incentive for participation in this program, Vineyard Town will waive the $20.00 utility application fee if you sign up. PLEASE ATTACH A VOIDED CHECK TO THIS FORM. Things to know about Direct Pay: • On your utility bill the following message will appear: ‘Automatic Payor’. This is your notification that direct pay has been activated and the next payment will be automatically deducted from your checking or savings account. (If you are a current customer and you are switching to direct pay after th 15th of the month, you wil need to manually pay your current payment.) • You must keep this payment arrangement in place for no less than 6 months from the date you sign this agreement or your account will be charged the $20.00 utility application fee. • You are authorizing the Town of Vineyard to debit your checking or savings account for all monthly charges for utility services. • If there are NOT sufficient funds in your checking or savings account to cover your bill, your utility account will be charged $10.00 for Non-Sufficient Funds (NSF). • Promptly notify the Town of Vineyard of any change to your checking or savings account. If a change occurs, it is your resposibility to provide the Town of Vineyard with the updated account information. • Two refused electronic fund transfers may cancel this agreement at the sole option of the Town of Vineyard. ACCOUNT INFORMATION ______________________________________________ Name of Financial Institution ______________________________________________ Bank Routing Number (9 digits) ______________________________________________ Bank Account Number
Checking Account
Savings Account
Use this image to determine which number on the check is the bank’s routing number and which is your account number.
I hereby authorize the Town of Vineyard to initiate automatic withdrawals from the financial institution indicated above for the purpose of paying my monthly utility bill. I understand that an automatic payment will be deducted from my account on the 20th of each month or the following business day if the 20th is on a weekend or holiday. I understand that I will be responsible to pay a non-sufficient funds fee as specified by the Town for any automatic debit that is returned due to insufficient funds. This authority is to remain in full force and effect until either (1) I revoke it by giving notice to the Town of Vineyard, by letter or by phone; (2) it is cancelled by the Town of Vineyard under the conditions stated above; or (3) upon termination of my service with the Town of Vineyard. I have read and agree to the terms and conditions outlined above. ________________________________________ Applicant Name (Please Print)
____________________ Utility Account Number
________________________________________ Applicant Signature
____________________ Date
FOR OFFICE USE ONLY Office Tech: Date:
