CITY OF LACY LAKEVIEW UTILITY DEPOSIT

PLEASE SUBMIT THIS FORM AND THE TCEQ AGREEMENT TO SET UP YOUR ACCOUNT

ALL NEW UTILITY DEPOSITS SUBMITTED AFTER 1 PM WILL NOT BE ELIGIBLE FOR SAME DAY TURN ON

DATE:*

SERVICE ADDRESS:*

ADDRESS-CITY-STATE-ZIPCODE

BILLING ADDRESS (IF DIFFERENT)

ALL BILLS WILL BE SENT TO BILLING ADDRESS IF DIFFERENT FROM SERVICE ADDRESS

NAME OF RESIDENT OR BUSINESS NAME:*

RESIDENTIAL/ COMMERCIAL/INDUSTRIAL*

PHONE NUMBER:*

ADDITIONAL PHONE NUMBER:*

Please enter a valid phone number.

EMAIL:*

example@example.com

UTILITY DEPOSIT AMOUNT:*

Deposit Amounts:

Residential: $200.00 Commercial/Industrial: $300.00 Fire Hydrant: $200.00 Temporary: $100.00

Residential New Construction : $150.00

Turn On fee: $25.00 (included on all new deposits)

(Please call for Hotel and Multi family living facilities.)

SOCIAL SECURITY NUMBER OR TAX ID *

SSN OR TAX ID IS REQUIRED

SOCIAL SECURITY NUMBER (IF TWO PEOPLE ARE LISTED ON THE UTILITY ACCOUNT)

ONLY FOR MULTIPLE RESIDENTS AT THE ACCOUNT-PLEASE SPECIFY WHICH SSN BELONGS TO WHOM

PHOTO IDENTIFICATION*

Acceptable forms of identification are:-DRIVER'S LICENSE OR IDENTIFICATION CARD-US PASSPORT OR PASSPORT CARD-MILITARY IDENTIFICATION CARD

PROOF OF LEASE/HOME OWNERSHIP/RENTAL AGREEMENT *

RESIDENTIAL ACCOUNTS: Proof of lease/Rental Agreement/Proof of Ownership

COMMERCIAL ACCOUNTS: Lease or Deed to the property (if you are not the owner, a letter stating that you have authority to open the account written on company letterhead)

Do you have a dog/dogs?*

YesNo

If you answered "yes" to this question, please fill out the Application for Pet Registration & License form. The Pet Registration fee is $5.00.

Please note: If you do not fill out this form, we cannot connect services.

Ordinance NO. 2014-01

I want my personal information kept confidential*

Subscribers signature*

COMPLETION STATUS

PLEASE SUBMIT THIS FORM AND THE TCEQ AGREEMENT TO SET UP YOUR ACCOUNT