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City of Oldsmar Reclaimed Water Connection Fee Installment Agreement

  1. ____________________________________________

    Customer Name

  2. ____________________________________________

    Service Address

  3. ____________________________________________

    Email

  4. ____________________________________________

    Date

  5. ____________________________________________

    Number

  6. Total Amount Due $320

  7. Utility Billing Use

  8. ____________________________________________

    Location Code

  9. ____________________________________________

    UB Account No.

  10. ____________________________________________

    Accepted By

  11. ____________________________________________

    Name of Applicant

  12. 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:

  13. OPTIONS (select one):

  14. Check if you understand and if applicable to you

  15. 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.

  16. ____________________________________________________________________________________________________________________________________

    Comments

  17. ____________________________________________

    Customer Printed Name

  18. ____________________________________________

    Customer Signature

  19. ____________________________________________

    Date

  20. Leave This Blank: