Applicant #2 - Full Name

I hereby request service from the Valparaiso City Utilities, Valparaiso, Indiana. I understand that services include water, water reclamation, storm water and trash service as applicable.

Bills for Cycle 1 are sent out before the 15th of each month for water and sanitation and that payment is due by the 1st of the following month after which a penalty is added to the amount due. Service shall be terminated if my bill is not paid by the 20th of that month and a collection fee will be added to the amount due.

Bills for Cycle 2 are sent out before the 5th of each month for water and sanitation and that payment is due by the 20th of the same month after which a penalty is added to the amount due. Service shall be terminated if my bill is not paid by the 10th of the following month and a collection fee will be added to the amount due.

I understand that I must have a responsible person available at the location of service mentioned above so that the service can be turned on and that the same shall apply when I have notified the Water Department that I desire service to be terminated.

I understand and acknowledge the Water Department cannot guarantee nor be responsible for the maintenance of water pressure or volume due to circumstances beyond its control.

I understand all parts of the Agreement and will comply with its terms.

Signature of Applicant 1

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Applicant 1 DOB (mm-dd-yyyy)

Signature of Applicant 2

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Applicant 2 DOB (mm-dd-yyyy)

Last 4 Digits SSN (applicant #1) OR TIN (business)

Last 4 Digits SSN (applicant #2)

Telephone number

Cell phone number

Mailing address if different than service address (P O Box, etc.)

Name, address and phone number of applicant #1

Name, address and phone number of applicant #2

Alternate contact persons name address and phone number

Property owner

Today date (mm-dd-yyyy)

Email address

Driver License

City, State, Zip

Bank Account Number

Bank Routing Number

I (we) have read the terms of this application and agree to the terms. This authorization will remain in full force and effective until the Valparaiso City Utilities has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the Valparaiso City Utilities and my financial institution a reasonable opportunity to act on it.

Signature for Authorization - Applicant1

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Date - Applicant1 (mm-dd-yyyy)

Signature for Authorization - Applicant2

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Date - Applicant2 (mm-dd-yyyy)

Address

Valparaiso City Utilities Account Number

Daytime Phone Number

Sign Up Now For Our Automatic Bank Payment Service!
With our free Automatic Bank Payment service, you can have your Valparaiso City Utilities bill automatically paid from any participating bank, savings and loan, or credit union account. First call your financial institution to see if it is capable of receiving electronic transmissions. Then complete the reverse side of this form and return it to us to start enjoying these benefits:
> No check to write.
> No postage to pay.
> No more monthly trips to pay your bill in person.
> No more embarrassments about forgetting to pay your bill.
> Away from home? Your bill will be paid and no late charges added.
All you have to do is make sure there is enough money in your account to cover the bills, and record the payments in your records.

With Automatic Bank Payment, you keep control of your monthly payments. You will continue to receive a monthly statement. On your due date, (the 1st or the 20th) the payment will be deducted from your account. That gives you plenty of time to review the statement and call our Billing Coordinator if you have any questions. If there is a billing error, call our Billing Coordinator at (219) 462-6174 ext. 1308 and we will make every effort to correct it as soon as possible.

When you see "We will automatically debit your bank account for the total charges of your bill. Do not send Payment" on your bill, you will know our Automatic Bank Payment Service is in effect.

You may cancel your automatic bank payment at any time you feel it is not working for you. We must receive written notification from you at least 10 days prior to your due date.

To sign up, fill out the application form and attach a scanned VOIDED check.

Terms of Agreement

Payment Notice, Payment Date and Billing Questions
You will continue to receive a monthly statement. You will have ample time to plan for your automatic payment or contact us if there is a question about your bill. On your due date, (the 1st or the 20th) the payment will be deducted from your account. If your due date falls on a weekend or holiday, your account will be charged on the next business day.
Availability of Funds
You are responsible for having enough money in the indicated account on the payment date. If the transaction cannot be processed for any reason, a past due notice will then be mailed to you and the payment must be made at our office. You will be responsible for all fees charged, should your payment be returned for any non-payment reason. (These fees may include late charges, non-payment fees, and collection fees.) Also, your automatic bank payment service may be cancelled if two payments are returned in a 12-month period for non-payment.
Record of Payment
The amount and date of your automatic payment will be shown on your regular bank statement. This is your proof of payment. If there is a question about a payment or if the amount differs from your bill for any reason, you must notify us and your financial institution within 60 days of the date on which the error is first reflected.
Account/Address Change
Please notify us of any account or address changes to ensure timely payments. You are responsible for submitting a new application when an account or address change occurs.
Termination
This authorization will remain in effect until we receive a written notice from you 10 days prior to cancellation date or until your service has been terminated and the final bill is paid in full. You may send us a letter requesting the cancellation of Automatic Bank Payment Service or stop by our office and sign a cancellation form.
Stop Payments
You should always advise us first of any request to stop payment. You may stop payment by notifying your financial institution at least three business days prior to payment due date. However, as when you stop payment on a check, you are responsible for any charges this may involve.

If you have any other questions, please call our office at (219) 462-6174 ext. 2 for customer service.