Security Deposit Template
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1SECURITY DEPOSIT
CITY SERVICES ~ Water/Sewer/Refuse
CITY OF TITUSVILLE CITY SERVICES DEPT - 107 N. Franklin St ~ Titusville, PA 16354 ~ (814) 827-5300 x 315 ~ Fax (814) 827-4359
A SECURITY DEPOSIT of $100.00 IS DUE WHEN OPENING A NEW ACCOUNT and is returned (with NO interest) at the end of ONE (1)
YEAR IF YOUR ACCOUNT IS CURRENT WHEN THE ONE YEAR TIME PERIOD IS UP. Security Deposits will be paid only to the person
named below and responsible for the account. Water Service will continue under this application unless we receive a request for a
final meter reading and forwarding address information.
THERE IS A ONE TIME / NON-REFUNDABLE $25.00 NEW ACCOUNT SET UP FEE THAT IS DUE WHEN OPENING AN ACCOUNT. THIS FEE
WILL BE ON YOUR FIRST BILL LISTED AS “New Account Charge-WATER $12.50” and “New Account Charge-SEWER $12.50”.
IF YOU MOVE within a year and continue to be a City Service customer, the deposit will carry over to your new address. Your final
bill must be paid in full before you can have City Services at another location. IF YOU MOVE within a year and are NO LONGER a
customer the Security Deposit will be applied to the balance due and a refund will be issued for any credit balance left on the
account. THERE IS A $25.00 MOVING FEE that will be assessed each and every time you move. This fee will also be separated out on
your first bill at your new address.
Account Number
Service Start Date
Customer Water Service Location Information
Customer Address for Sending Bill (if different)
Customer Name
Customer Name
Address
Address
City, State, Zip
TITUSVILLE PA 16354
City, State, Zip
Phone Number
Rent
Own
Cell Number
Have you held Titusville services in your name?
Email Address
At what address? _____________________________
Emergency Contact Name
Copy Photo ID Here
Phone Number
Landlord Information (Complete only (if renting)
Landlord's Name
Phone Number
Additional adult tenant(s) (Complete only if renting)
Please Note: Landlords are notified of any delinquency and will
receive account information if requested.
** Office Use Only**
Cash / Check #
_________
Paid By ___________________
Customer Signature _______________________________ Date _______________
Date rcvd ____ /____ / _______
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Parent category: Business