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2. ____________________________________________
   Customer Name
3. ____________________________________________
   Service Address
5. ____________________________________________
   Email
6. ____________________________________________
   Date
7. ____________________________________________
   Number
9. Total Amount Due $320
13. Utility Billing Use
15. ____________________________________________
    Location Code
16. ____________________________________________
    UB Account No.
18. ____________________________________________
    Accepted By
19. ____________________________________________
    Name of Applicant
21. I ________________________________________________________ acknowledge the above amount to be due for the Reclaimed Water Connection fee. I also agree to have this fee added to my utility bill in monthly installments as indicated below:
23. OPTIONS (select one):

    1. 2 monthly installments of $160
    2. 4 monthly installments of $ 80
    3. 8 monthly installments of $ 40
24. Check if you understand and if applicable to you

    1. understand that failure to pay the amount of the utility bill in full each month, including the installment agreed to above, will result in disconnection of my utility service.
    2. I am the owner of the utility account.
26. The monthly installments will commence the billing cycle following acceptance of this application and continue each month until the $320 reclaimed water connection fee has been paid in full.
28. ____________________________________________________________________________________________________________________________________
    Comments
30. ____________________________________________
    Customer Printed Name
31. ____________________________________________
    Customer Signature
33. ____________________________________________
    Date
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34. Print Only

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