Water/Sewer/Garbage Form: New Service Application

Start Service Date:

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New services are only available Monday - Friday (with the exception of holidays)

Garbage Can Size

95 Gallon (Standard size)

65 Gallon

Customer Type: *

Residential (Owner)

Residential (Rental)

Commercial

Service(s) Requested: *

Water

Sewer

Garbage - monthly charge $19.90

The water and sewer department reads meters around the 15th of each month. Each customer will be billed for the previous month's usage. Customer(s) will be responsible for month's usage whether they receive a bill or not. Payment of water/sewer/garbage is due by the 10th of every month. A $10.00 late fee penalty is charged on all late payments received after the 15th. I agree to pay the minimum payment per month for water/sewer/garbage. I agree to pay for all water consumed and I agree to pay for all sewage charges if connected to city sewer lines. A $165.00 deposit is required at the time this application is made. After the applicant has vacated the premises and the final bill has been paid in full, $150.00 of the deposit will be refunded or applied to any outstanding balance, with any remaining funds due to customer sent in the form of a check to the forwarding address supplied to the City upon completion of the termination form. ($15.00 is a non-refundable administrative service fee). City Garbage service is a $19.90 monthly charge. The City will provide one 65-gallon or one 95-gallon single rolling garbage container. Upon cancelation of garbage service, trash can must be returned. If can is not returned, a fee of $60.00 or the current replacement cost will be deducted from the deposit. Pick-up is on Wednesday from 6:00 am until 6:00 pm unless garbage service occurs on a holiday, then pick-up will be on the next following business day. Holidays include New Year's Day, Memorial Day, July 4th, Labor Day, and Christmas Day. Garbage container must be out by 6:00 a.m. to ensure pickup. Nonpayment within 30 days of the date of the bill will result in water and/or sewer service disconnected and/or garbage service being discontinued. Your account will be subject to re-connection fee(s) as per the City Ordinance section. All returned check(s) will have a Returned Check Service Charge of $35.00. All fees and rates are subject to change. When I move, I will notify the City Water Department by submitting a termination form at least three (3) days in advance.

First Name: *

Last Name: *

What is the service address for the services you are requesting: *

Mailing Address: *

City: *

State: *

Zip Code: *

Cell Phone #: *

for example: 000-000-0000

Email Address: *

BY PROVIDING YOUR EMAIL ADDRESS, YOU UNDERSTAND THAT ALL MONTHLY BILLS WILL BE SENT VIA EMAIL ONLY. NO PAPER BILLS WILL BE MAILED.

Employer: *

Work telephone #: *

for example: 000-000-0000

Name of Emergency Contact: *

Emergency Contact Telephone Number: *

Driver License/Photo ID Upload: *

Please attach a scan or photo of your Driver's License/Photo ID
Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png bmp pdf doc docx.

Proof of Ownership/Lease Agreement: *

Provide proof of ownership or rental/lease agreement
Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png bmp pdf doc docx.

Authorization Agreement For Direct Payments (ACH Debit):

Checking Account

Saving Account

I (we) hereby authorize CITY OF DAWSONVILLE, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account or Savings Account indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

Authorization For Direct Payments (ACH Debit):

Please upload a VOIDED CHECK from your banking institution.
Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png pdf.

Depository (Bank) Name:

Routing Number:

Account Number:

Authorization for DEPOSIT- ONE TIME CHARGE

I (we) authorize CITY OF DAWSONVILLE, hereinafter called COMPANY, to process a ONE TIME CREDIT CARD PAYMENT of $165.00, plus a 3% processing fee, to be applied to the deposit for requested service(s). This is a ONE TIME charge and DOES NOT establish a recurring payment. Please enter a valid credit card number and the 4-digit expiration date. i.e., 01/21.

Applicant's Signature: *

By signing, I hereby certify that I have personally inspected the entire house and/or business for which the water is to be "turned on" for water leaks, toilet leaks, outdoor faucet leaks, sprinkler system leaks, washing machine leaks, etc. and that THERE ARE NO LEAKS AND THAT THE CITY IS HEREBY HELD HARMLESS FOR TURNING THE WATER ON TO MY UNIT.

Message:

Date:

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Water/Sewer/Garbage Form: New Service Application

Contact Information