Residential Service Application

HERNANDO COUNTY UTILITIES

RESIDENTIAL SERVICE

Water Only

Applicant	Deposit	Service Charge	Total
Owner	$60	$100	$160
Tenant	$100	$100	$200

Water/Sewer

Applicant	Deposit	Service Charge	Total
Owner	$235	$100	$335
Tenant	$375	$100	$475

Irrigation

Applicant	Deposit	Service Charge	Total
Owner	$60	$100	$160
Tenant	$100	$100	$200

*Irrigation is included if turned on at the same time as water/sewer

The undersigned applicant(s) for water/sewer service agree(s), jointly and severally, if applicable, to conform to and abide by all the rates, rules and regulations provided by ordinance, code, resolution or otherwise of the Hernando County Water and Sewer District for water and/ or wastewater service as are now or hereafter in force and which are a part of this contract. Applicant(s) further agree(s), jointly and severally if applicable, to pay water and wastewater hookup and connection fees where applicable amd to pay all charges for water and/or wastewater service, as they may become due and at the scheduled rate in effect, unless and until notice in writing is given by the applicant(s) to the District through the Utilities Department that service is to be discontinued for whatever period of time. Connection fees paid to the Utilities Department are non-refundable by ordinance.

YESNO
If so, please provide service address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
APPLICANT - FULL NAME (if Business type N/A)*

First NameMiddle NameLast Name
APPLICANT- Business Name (if not a business type N/A)*
APPLICANT - EMAIL*
example@example.com
APPLICANT - PHONE NUMBER *

Area CodePhone Number
APPLICANT - LAST 4 DIGITS OF SOCIAL SECURITY or EIN*
APPLICANT - PLEASE UPLOAD ONE OF THE FOLLOWING: DRIVERS LICENSE, PASSPORT, OR IDENTIFICATION CARD (SELFIES ARE NOT AN ACCEPTABLE FORM OF IDENTIFICATION).*

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APPLICANT - MAILING ADDRESS (Invoices are sent to this address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CO-APPLICANT - FULL NAME

First NameMiddle NameLast Name
CO-APPLICANT - PHONE NUMBER

Area CodePhone Number
CO-APPLICANT - LAST 4 DIGITS OF SOCIAL SECURITY
CO-APPLICANT - PLEASE UPLOAD ONE OF THE FOLLOWING: DRIVERS LICENSE, PASSPORT, OR IDENTIFICATION CARD (SELFIES ARE NOT AN ACCEPTABLE FORM OF IDENTIFICATION).

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YesNo
CURRENT SERVICE LOCATION:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
IF YES, WHAT DATE ARE YOU DISCONNECTING SERVICE?

MonthDayYear
Date
TENANTAGENT/PROPERTY MANAGEMENTOWNER

YesNo

YesNo
FOR OWNERS, VERIFIABLE PROOF OF OWNERSHIP IS REQUIRED. PLEASE UPLOAD YOUR DOCUMENTATION.

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IF APPLICABLE:
- TITLE COMPANY
- TITLE COMPANY PHONE NUMBER
- ESCROW/FILE NUMBER
- CLOSIING DATE
TITLE COMPANY
TITLE COMPANY PHONE NUMBER

Area CodePhone Number
ESCROW/FILE NUMBER
CLOSING DATE

MonthDayYear
Date

TENANTS, THE FOLLOWING DOCUMENTATION IS REQUIRED:
- Lease Terms and Signature Page or Notarized Letter of Authorization
- Valid Government-issued photo ID
- Deposit and Service Charge
UPLOAD YOUR LEASE OR LETTER OF AUTHORIZATION*

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ANY ADDITIONAL DOCUMENTATION (OPTIONAL)

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AGENT/PROPERTY MANAGERS, THE FOLLOWING DOCUMENTATION IS REQUIRED:
- Property Management Agreement
- Valid Government-issued photo ID
- Deposit and Service Charge
UPLOAD YOUR PROPERTY MANAGEMENT AGREEMENT*

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ANY ADDITIONAL DOCUMENTATION (OPTIONAL)

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SERVICE ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parcel Key #:
PLEASE ENTER THE DATE THE SERVICE NEEDS TO BE TURNED ON:*

MonthDayYear
Excluding Weekends and Holidays

I acknowledge that I have been advised to be present at the above mentioned property at the time of water being turned on.I understand that if I choose not to be present or have my authorized agent present at the time of the water being turned on, I hereby accept all responsibility for any damages and charges resulting from leaking, vandalism or negligence and further hold Hernando County harmless and without liability whatsoever.I further understand that if the water meter indicates flow and/or a possible leak, the meter and service will not be left on and an additional trip charge will be billed to my account.
Yes, I claim a Public Records ExemptionNo, I can not claim an exemption
REASON FOR EXEMPTION
Please type in your first and last name below to signify you agree that the information you have provided is correct to the best of your knowledge.
APPLICANT - SIGNATURE

Clear
CO-APPLICANT - SIGNATURE

Clear
APPLICATION'S SIGNATURE*
CO-APPLICANT'S SIGNATURE
Should be Empty:

HERNANDO COUNTY UTILITIES

Water Only

Water/Sewer

Irrigation