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City of Oldsmar Reclaimed Water Connection Fee Installment Agreement

2. ____________________________________________
   Customer Name

   Customer Name

3. ____________________________________________
   Service Address

   Service Address

5. ____________________________________________
   Email

   Email

6. ____________________________________________
   Date

   Date

7. ____________________________________________
   Number

   Number

9. Total Amount Due $320

13. Utility Billing Use

15. ____________________________________________
    Location Code

    Location Code

16. ____________________________________________
    UB Account No.

    UB Account No.

18. ____________________________________________
    Accepted By

    Accepted By

19. ____________________________________________
    Name of Applicant

    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

    Comments

30. ____________________________________________
    Customer Printed Name

    Customer Printed Name

31. ____________________________________________
    Customer Signature

    Customer Signature

33. ____________________________________________
    Date

    Date

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