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Get City Of Wray Utilities Form

OFFICE USE ONLY Identification Deposit/Act. Service Order CITY OF WRAY APPLICATION FOR UTILITY SERVICE 245 W 4TH - PO BOX 35 - WRAY CO 80758 - 970 332-4431 APPLICANT SERVICE ADDRESS MAILING ADDRESS CITY STATE ZIP DATE OF BIRTH HOME PHONE SOCIAL SECURITY NUMBER DRIVER S LICENSE NUMBER STATE EMPLOYER NAME/ /PHONE HAVE YOU HAD UTILITIES WITH THE CITY OF WRAY IN THE PAST NO YES IF SO PLEASE GIVE THE YEAR OF SERVICE. BANK NAME TYPE OF SERVICE REQUESTED RESIDENTIAL COMMERCIAL NEXT OF KIN NOT LIVING IN SAME HOUSEHOLD NAME ADDRESS PHONE NUMBER DATE TO BEGIN SERVICE I authorize the following person s to have full access to my account. I do hereby certify that I am the above named applicant and that I will be responsible for payment of utility services provided at the above address from the requested date of service until I have properly notified the City of Wray to discontinue said service and that any utility deposit will be returned to me after the final bill has been paid in full* Failure to pay the bill in full in a timely manner will result in submitting the above information to a credit agency for collection of utility bill* Interest will accrue at 8 per annum if turned to a collection agency. Court costs including the court filing fee service fee and e-file fee for summons complaints garnishments and transcripts in addition to reasonable attorney fees will be the responsibility of the adult person s named on the account if account is placed with a collection agency. A reasonable collection cost of thirty-three and one third percent 33. 33 which is the cost associated with the collection of accounts will also be added to the principal balance of the account if turned to collections. SIGNATURE OF APPLICANT DATE UTILITY ACCOUNT NUMBER DEPOSIT AMOUNT ACTIVATION FEE DATE PAID APP0300 REVISED 6/11. I do hereby certify that I am the above named applicant and that I will be responsible for payment of utility services provided at the above address from the requested date of service until I have properly notified the City of Wray to discontinue said service and that any utility deposit will be returned to me after the final bill has been paid in full* Failure to pay the bill in full in a timely manner will result in submitting the above information to a credit agency for collection of utility bill* Interest will accrue at 8 per annum if turned to a collection agency. Court costs including the court filing fee service fee and e-file fee for summons complaints garnishments and transcripts in addition to reasonable attorney fees will be the responsibility of the adult person s named on the account if account is placed with a collection agency. Court costs including the court filing fee service fee and e-file fee for summons complaints garnishments and transcripts in addition to reasonable attorney fees will be the responsibility of the adult person s named on the account if account is placed with a collection agency. A reasonable collection cost of thirty-three and one third percent 33. 33 which is the cost associated with the collection of accounts will also be added to the principal balance of the account if turned to collections.

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