Residential Service Application

HERNANDO COUNTY UTILITIES

RESIDENTIAL SERVICE
*FORM MUST BE COMPLETED IN ITS ENTIRETY ALONG WITH ALL REQUIRED DOCUMENTATION TO PROCESS.

* DEPOSITS ARE APPLIED TO YOUR FIRST STATEMENT/BILL

*OVERTIME CHARGES MAY APPLY FOR SERVICE REQUESTS AFTER 3:30PM
APPLICANT - FULL NAME*

First NameMiddle NameLast Name
APPLICANT - EMAIL*
example@example.com
APPLICANT - PHONE NUMBER *

Area CodePhone Number
APPLICANT - LAST 4 DIGITS OF SOCIAL SECURITY*
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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DO YOU CURRENTLY HAVE WATER SERVICE WITH HERNANDO COUNTY?*

YesNo
CURRENT SERVICE LOCATION:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ARE YOU DISCONNECTING WATER SERVICE AT THIS LOCATION?*

YesNo
IF YES, WHAT DATE ARE YOU DISCONNECTING SERVICE?

MonthDayYear
Date
WHO IS COMPLETING THIS APPLICATION?*

TENANTAGENT/PROPERTY MANAGEMENTOWNER

OWNERSHIP: HAVE YOU OWNED THE PROPERTY WHERE YOU ARE STARTING SERVICE FOR MORE THAN SIX (6) MONTHS?*

YesNo

DO YOU CURRENTLY HAVE "PROOF OF OWNERSHIP" DOCUMENTS TO UPLOAD?*

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

CONTRACT AND WAIVER (MUST ACKNOWLEDGE/CHECK ALL)*

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.
PUBLIC RECORDS EXEMPTION (ALTERNATIVE)

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