Fillable Utility Activation Authorization De-Winterization (Page 3 of 5) in pdf

UTILITY ACTIVATION FORM

_____________________________

____________―______________________________

Date:

HUD Case #:

________________________________ C

Property Address:

ity: ______________________ State: _______ Zip: ___________

Buyer’s Agent: ___________________________________________ Agent Cell#: _________________________________________

Agent Email: ____________________________________________ Agent Fax #: __________________________________________

Purchaser(s):______________________ Purchaser Cell: _____________________ Purchaser Email:___________________________

You

MUST

(1) have all accounts activated, and (2) provide ALL of the following information

BEFORE

we will process your application.

Water Utility Company: _______________________________

Phone number: _____________________________________

Account #: _________________________________________

Date of Activation: __________________________________

Gas Utility Company: _________________________________

Phone number: _____________________________________

Account #: _________________________________________

Date of Activation: __________________________________

Electric Utility Company: ______________________________

Phone number: _____________________________________

Account #: _________________________________________

Date of Activation: __________________________________

_______________________________________________

__________________________________________________

Scheduled Buyer’s Inspection Date

Utility De-Activation Date

Payment Method (circle one):

CASHIER’S CHECK/MONEY ORDER

CREDIT CARD

Payment Information:

Person Responsible for Payment: Name _______________________________ email: ____________________________________

Billing Address: ________________________________ City: _________________________ ST: _________ Zip: _______________

ACKNOWLEDGEMENT: The Purchaser and the Selling Agent must acknowledge all the following 5 statements. (1) The undersigned Purchaser and

Selling Agent hereby agree to forever hold harmless the U.S. Department of Housing and Urban Development, A2Z Field Services, and its

subcontractors from any and all liability, damages and/or claims from the like, rather directly or indirectly, which may arise from the use of this

form and/or the activation, connection and/or de-activation of any utilities regardless of its origin or nature. (2) The utilities are defined as water,

gas, electric, and/or any other service, material, item, or product required to operate and/or test any system and/or item on the above identified

property. (3) The undersigned will assume all and full financial responsibility for any damages which may occur as a result of any actions and agrees

to pay immediately for the remediation and/or correction of any and all damages caused during the time the utilities are activated or de-activated

for inspection. (4) All utilities are to be turned on in the name of the purchaser. (5) Purchaser may not in any way occupy, perform work on, or alter

securing and/or entry locks of said property until the official closing is complete. (6) Selling agent must be present when all utilities are activated at

the property.

___________________________/___________

__________________________/___________

Purchaser Signature/Date

Agent Signature/Date

Do not write below this line

The following utilities are authorized by A2Z Field Services to be activated:

GAS: Yes – No

ELECTRIC: Yes - No

WATER: Yes - No - Air test only

Due date for Deactivation Form: __________________ De-winter _______________________ Re-winter ____________________

Authorized by: ____________________________________________ Signature: __________________________________________