Water & Sewer Customer Service Request Reason for Change(Required)Note: This is a universal form. Please check all boxes that apply and complete the applicable sections below. Move In Move Out Turn On Turn Off Cancel ACH Effective Date(Required) MM slash DD slash YYYY Please provide requested turn-off time if for repairsApplicant InformationToday's Date(Required) MM slash DD slash YYYY Phone(Required)Account NumberEmail(Required) Service Address(Required)Billing Address(Required)Type "Same" if billing address is the same as above Service AddressApplicant is:(Required) Property Owner Tenant Property Manager/Rep Change Option - Change in Billing Information/Final Bill Mailing AddressNEW Name/Moving InFINAL BILL REQUEST ‐ Water meter will be read, and a bill calculated based on either the date of request/receipt Postmarks are not accepted, and requests cannot be backdated Sewer only accounts ‐ Will be pro‐rated based on either the date of request/receipt Water and sewer bills are billed on a quarterly basis and are billed based on the meter reading/property and not by the occupant. If you need the meter read and a bill sent to previous owner/occupant indicated by checking the COMPLETE FINAL BILL box.COMPLETE FINAL BILL YES, $85.00 charge Final Bill Mailing AddressChange Option - Turn On/Turn OffEach Service Request is $49.00 Charge Turn Water On Turn Water Off PLEASE ALLOW 48 HOUR NOTICE FOR NON-EMERGENCY REQUESTS. AFTER HOURS EMERGENCY SERVICE IS $214.00 CHARGE/EACHChange Option - ACH ChangeCancel Current Automatic Payment (ACH)You must choose Yes if you wish to cancel current ACH. Yes Applicant SignatureApplicant Consent(Required)I agree to using an electronic signature. By mouse/finger signing, file upload and/or typing my name below, I agree to using an electronic signature.I am unable to use finger/mouse or file upload to sign and will only type my name in "Signature Typed" box below.Ignore this input if you plan to sign by finger/mouse or file upload. Yes Applicant SignatureI am uploading my signature instead of finger/mouse signing.I choose to upload a digital version of my signature.Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 512 MB.Typed Applicant Signature(Required)United States Department of Agriculture Data CollectionDear Charter Township of Union Water and Sewer Customer: Charter Township of Union is required to collect and report data annually as part of the Rural Development program, a federally funded loan program. Listed below is the data we are to collect from our water and sewer customers, as well as the required disclosure statement. Please take the time to complete the questions at the bottom of the form and return it to Charter Township of Union. If you wish not to provide this information, please check the appropriate line and return the form. The following Information is requested by the Federal Governmentinorder to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you In any way. However, if you choose not to furnish it, we are required to note the race, ethnicity and sex of applicants on the basis of visual observation or surname Request for Information Denied I do not wish to furnish this information. Ethnicity Hispanic or Latino Not Hispanic or Latino Race: (Mark all that apply) White Black or African American American Indian or Alaska Native Asian Native Hawaiian or other Pacific Islander Sex Male Female Consent(Required) I agree to the Privacy Policy and Security Notice. Δ
