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2. 
4. Note:

   All water users will make a deposit to the City of Elgin prior to obtaining service. The standard deposit fee will be $200 plus a $50 application fee.

6. 
8. Service Start Date*
   Service Start Date
10. New Service Address*
    Elgin, TX 78621
12. Mailing Address
14. City
15. State
16. Zip Code
20. CUSTOMER INFORMATION
22. Primary Name (printed on the bill)*
24. Date of Birth*
    Date of Birth
26. Home Phone Number*
27. Work Phone Number
29. Cell Phone Number
30. Alternative Phone Number
32. Secondary Name (not printed on the bill):
34. Date of Birth
    Date of Birth
36. Home Phone Number
37. Work Phone Number
39. Cell Phone Number
40. Alternative Phone Number
44. PREFERRED BILLING INFORMATION
46. Preferred Billing Method*

    1. PAPER BILL – U.S. MAIL
    2. PAPERLESS BILL – EMAIL
47. Primary Email
51. Information Confidentiality

    Please check the box to elect to have your information remain confidential. Utility customers have the right to request confidentiality of personal information. Personal information is defined as “an individual social security number, address or telephone number”. Typically, these things have been available routinely through an Open Records Request. All other information on your account is still subject to the terms of the Open Records Act. Further, this information is still available to other utility suppliers, law enforcement agencies, government officials and consumer reporting agencies.
55. Initial*

    Customers are responsible for the timely payment of their Utility Bill whether the bill is received or not. Utility bills are mailed to customers every month and are due on the date printed on the bill each month. If you do not receive your utility bill, please contact the Utility Billing Department as soon as possible.

57. Initial*
    Customers are responsible for reviewing the accuracy of their Utility Bill. If you find an error, please contact the Utility Billing Department as soon as possible.
59. Initial*

    If not paid by the due date, a penalty of 10% of the unpaid balance is applied to the account. Full payment including penalty charge is due no later than the 10th day after the due date of the bill.

61. Initial*

    Service will be disconnected if full payment is not received on or before the10th day after the due date of the bill and will include a fee of $75.00. This is an administrative fee and will be charged whether your service is disconnected or not.

63. Initial*
    To restore service the past due balance and all penalties must be paid. After payment is received, service will be restored by the end of business day.
65. Initial*
    Services restored AFTER HOURS will be charged an additional $50.00 after hours connection fee.
67. Initial*
    It is unlawful for any person or property owner to reconnect or attempt to reconnect service and is punishable by fine up to $100.00. If meters are found to be tampered with (locks cut, etc.) fees will be charged to the account.
69. Initial*
    Please keep meter box areas easily accessible to City Staff and free of debris/growth.
71. 
73. Visit City of Elgin Website
75. I certify that all the above information is true and correct to the best of my knowledge. Also, I acknowledge that any previous City Of Elgin Utility Account balances owed by me or authorized person listed above will be due at the time of service.
77. Payment

    Payment accepted in the form of: cash, check, money order, Visa, MasterCard or Discover only ($3 convenience fee). Make check or money order payable to the City of Elgin Utilities. Once account is established and confirmation email has been sent by the Utility Billing Department, deposit payment must be made in person or over the phone.

79. Signature*
80. Date*
    Date
84. Attach Documents
86. Please provide a copy of a legal lease agreement listing all occupants over the age of 18 living in the home. OR a copy of the Settlement Page if you have purchased the property. A tax statement will also be accepted for property owners.*
    Attach file here
90. For office use only
93. 
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit

* indicates a required field