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Get VA Tenant Authorization 2014-2024

TENANT AUTHORIZATION Print and Remit Completed Form to FAIRFAX WATER Attn Customer Service 8570 Executive Park Avenue Fairfax VA 22031 tenantform fairfaxwater. Completion of this form is required to establish new Tenant Service. Tenant accounts will not be opened without a completed form and the required Lien Offset payment of 190. 00. To be paid by the Tenant by cash money order or check payable to Fairfax Water. For your convenience and a fee we also take check and credit card payments by phone and online via Speedpay. Call us for more information. Service Address Service Start Date The following tenant s have entered into a lease agreement for the referenced service address and is are authorized to obtain services from Fairfax Water at this address as my tenant s. Please print the first and last name of each tenant on the lease agreement. Tenant Name Tenant Contact Information Phone H C Email Lien Offset may be waived for tenants who receive need based local state or federal rental assistance. If your tenant receives rental assistance please provide documentation with this form. Property owner information - Please provide first and last name mailing address different from the service address and contact information. Owner Name Street City State Zip Code Signature Property Owner or Authorized Agent Print Name Date For more information please visit www. org Phone 703 698-5800 Fax 703 466-6863 This form must be signed by the legal recorded property owner or authorized property manager. Completion of this form is required to establish new Tenant Service. Tenant accounts will not be opened without a completed form and the required Lien Offset payment of 190. 00. To be paid by the Tenant by cash money order or check payable to Fairfax Water. For your convenience and a fee we also take check and credit card payments by phone and online via Speedpay. Call us for more information* Service Address Service Start Date The following tenant s have entered into a lease agreement for the referenced service address and is are authorized to obtain services from Fairfax Water at this address as my tenant s. Please print the first and last name of each tenant on the lease agreement. Tenant Name Tenant Contact Information Phone H C Email Lien Offset may be waived for tenants who receive need based local state or federal rental assistance. If your tenant receives rental assistance please provide documentation with this form* Property owner information - Please provide first and last name mailing address different from the service address and contact information* Owner Name Street City State Zip Code Signature Property Owner or Authorized Agent Print Name Date For more information please visit www. fairfaxwater. org Office Use Only Lien Offset received Amount Received Updated 08/20/2014 Cash Check Money Order Account Number Speedpay Lien Offset Waived Received By. org Phone 703 698-5800 Fax 703 466-6863 This form must be signed by the legal recorded property owner or authorized property manager. Completion of this form is required to establish new Tenant Service. Tenant accounts will not be opened without a completed form and the required Lien Offset payment of 190. .

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