Fillable Water/sewer Tenant Direct Billing Agreement printable pdf download

CITY OF COLUMBUS

DEPARTMENT OF PUBLIC UTILITIES

WATER/SEWER TENANT DIRECT BILLING AGREEMENT

Tenant Name*:

Deeded Owner*:

Service Address*:

Tenant Customer #:

Owner Customer #:

Tenant Social Security or Tax ID #*:

Owner Social Security or Tax ID #*:

Premises #:

In order to process the Tenant Direct Billing Agreement, it is necessary to obtain a reading from the INSIDE WATER METER and provide

the date the reading was obtained. Most properties are equipped with an OUTSIDE REMOTE REGISTER, please obtain the reading from this

device the same day as the inside water meter reading. The remote register is a 3 inch by 4.5 inch blue and black box with a clear plastic cover

located on the outside of the property. We will attempt to begin service as close to the date the reading was obtained as scheduling will allow.

DATE READINGS WERE OBTAINED*:

INSIDE METER READING*:

OUTSIDE REMOTE READING:

Note: Failure to provide the INSIDE WATER METER reading may result in an interruption of water service. This Tenant Direct Billing

Agreement may be returned to the owner unprocessed if any of the following occur: the inside water meter reading and date of reading are not

provided, there are delinquencies on an account under the property owner’s liability, or if any of the information required on this agreement

is missing or illegible. * Indicates required information.

The undersigned agree that water/sewer bills for the above service address are to be mailed directly to the above tenant for payment. This agreement is subject to City of

Columbus codes and regulations regarding the provision of water and sewer service by the Division of Water and the Division of Sewerage and Drainage.

We understand that water/sewer service is granted solely on the basis of personal information submitted as part of this agreement and we do certify that all such

information is correct. We agree that this application for service, when accepted by the City of Columbus, shall form a binding agreement governing the terms of all

water and sewer services rendered to us by the City of Columbus.

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Property Owner Agreement:

I understand and agree the tenants at the service address covered by this agreement are to be authorized to receive water/sewer bills as agents for me.

I understand and agree that this agreement does not relieve me of property owner liability as described in Columbus City Code 1105.045 and

1147.16, and I am responsible for all charges to the above service address, such as unpaid water and sewer charges accrued by tenants.

Once the Tenant Direct Billing Agreement becomes effective, I understand that I will receive copies of all bills and delinquent/turn off notices

regarding the above service address. I also understand the tenants may be granted payment extensions on delinquent bills and by signing this

agreement, I authorize the City of Columbus to grant such extensions.

Property Owner/Authorized Agent Name* (please print)

Mailing Address for Bills and Notices*

Property Owner/Authorized Agent Signature*

Date

Phone Number*

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Tenant Agreement:

I understand and agree to prompt payment of any and all water/sewer charges for the above service address accrued during the period I am leasing

the property covered by this Tenant Direct Billing Agreement.

Tenant’s Name* (please print)

Tenant’s Signature*

Date

Phone Number*

Please return completed and signed form to: Department of Public Utilities, Customer Service Center, 910 Dublin Rd., Columbus, Ohio 43215-9060

or Fax: 614-645-0222. You may also scan and email a signed form to utilityleadrep@columbus.gov.

* Indicates required information.

9/23/13