Form Center

2. Personal or Business*

   1. Personal

   1. Business
4. First Name*
5. Last Name*
6. Service Start Date*
   Service Start Date
7. Owner Date of Birth*
   Owner Date of Birth
9. Cell Phone Number*
10. Business Name*
12. Drivers License Number*
13. Business Federal Employer Identification Number*
15. Email Address*
17. Service Address*
19. City*
20. State*
21. Zip Code*
23. Mailing Address*
25. City*
26. State*
27. Zip Code*
29. Secondary Owner's Name
30. Cell Phone Number
31. Work Phone Number
33. RULES AND REGULATIONS GOVERNING WATER SERVICE

    SERVICE CHARGE: There is a monthly service charge based on a fixed-scale meter rate. 

    3/4 " meter and less . . . . . . . . . . . . . . . .  $ 19.98 

    1" meter . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35.56 

    1.5" meter . . . . . . . . . . . . . . . . . . . . . . . .  $ 79.92 

    2" meter . . . . . . . . . . . . . . . . . . . . . . . . . $ 142.06 

    3" meter . . . . . . . . . . . . . . . . . . . . . . . . . $ 319.68 

    4" meter . . . . . . . . . . . . . . . . . . . . . . . . . $ 568.23

    BILLING: All charges for use of the water system are payable upon receipt of water bills within a 20-day grace period for payment. Bills are rendered monthly. Bills are calculated based on metered usage. The owner of the premises and the occupant thereof and the user of the services shall be liable for the payment of all charges for services. 

    PENALTIES: The following penalties are applicable to unpaid water bills: 

    1. After twenty-one (21) days from the bill date, a penalty of ten (10) percent charge will be assessed. 

    2. After thirty-four (34) days from the bill date, a fifty (50) dollar termination charge will be assessed. 

    TERMINATION OF WATER SERVICE: Termination of water service may result because of non-payment of a bill thirty-four (34) days past the billing date, payment of a bill by check not honored by the payer bank and/or failure to comply with any of the ordinances governing the use of Village water service. Payment of all outstanding account charges is required prior to restoring service. Payments received after 3:00 pm may result in up to 24 hours to have the service reinstated. To reinstate service the customer shall comply with the ordinances governing the specific situation. 

    THE RULES AND REGULATIONS GOVERNING WATER SERVICE ARE SUBJECT TO CHANGE BY THE VILLAGE BOARD. 

    AGREEMENT: I accept all provisions of, agree to abide by and agree to comply with all the ordinances governing the use of Village Water and Sewer service and understand failure to comply may result in the termination of Water and Sewer service. 

    I certify that the information I have provided is true and correct. 

    
    

35. Driver's License Front*

    Upload your driver's license (Front)

37. Today's Date*
    Today's Date
38. Name*

    DISCLAIMER: By typing your name here, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

40. Today's Date
    Today's Date
41. Name

    DISCLAIMER: By typing your name here, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field