ACCT # ___________________________
DATE SET ________________________
PAID $______ __ CASH __CK __ CARD
RECEIPT # ____________ METER INSTALL ___
METER DEPOSIT ______
SERIAL # ______________ EID _____________
THE CITY OF DEMOREST
APPLICATION FOR RESIDENTIAL WATER SERVICE
APPLICANT NAME
LAST NAME
FIRST NAME
MIDDLE NAME
FIRST NAME
MIDDLE NAME
SPOUSE/ROOMMATE NAME
LAST NAME
SERVICE ADDRESS
YES
STREET
CITY
STATE
ZIP CODE
NO
INSIDE CITY
MAILING ADDRESS (IF DIFFERENT FROM SERVICE ADDRESS)
STREET OR P O BOX
CITY
STATE
ZIP CODE
APPLICANT DRIVER’S LICENSE NUMBER
APPLICANT SOCIAL SECURITY NUMBER
SPOUSE/ROOMMATE DRIVER’S LICENSE NUMBER
SPOUSE/ROOMMATE SOCIAL SECURITY NUMBER
HOME TELEPHONE
CELL PHONE
EMAIL ADDRESS
SPOUSE/ROOMMATE CELL PHONE
ALTERNATE EMAIL ADDRESS
IF THIS IS A RENTAL PROPERTY:
OWNER NAME
OWNER ADDRESS
OWNER TELEPHONE
APPLICANT EMPLOYER
EMPLOYER ADDRESS
EMPLOYER TELEPHONE
SPOUSE/ROOMMATE EMPLOYER
EMPLOYER ADDRESS
EMPLOYER TELEPHONE
HAVE YOU PREVIOUSLY HAD WATER SERVICE WITH THE CITY OF DEMOREST?
YES
NO
IF YES, LIST PREVIOUS SERVICE ADDRESS:
“The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against
applicants seeking to participate in the 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, national origin of
individual applicants on the basis of visual observation or surname.”
__ White, not of Hispanic origin
__ Hispanic
__ Black, not of Hispanic origin
__ Asian or Pacific Islander
__ American Indian or Alaskan native
__ Bi-Racial
“This is an Equal Opportunity Program. Discrimination is prohibited by Federal law. Complaints of discrimination may be filed with the Secretary of Agriculture,
Washington, DC 20250.”
I am applying for service with the City of Demorest. I have received the Water User Agreement provided with this application, and I
understand the terms and conditions of this application and the Water User Agreement and agree to abide by the terms and conditions.
APPLICANT SIGNATURE
DATE
SERVICE TERMS AND CONDITIONS
1. Bills are prepared once a month and are due and payable on the due date indicated on the bill. A 10%
charge will be added to any unpaid balance after the due date.
2. Non-payment within 30 days from the due date shall result in water being disconnected from the
property. Payment cannot be made in the field. The disconnection crew lacks authority to accept
payment.
3. Once service has been disconnected, restoration of service will require payment in full of the
outstanding invoice, a security deposit approved by the Mayor and City Council, and a service charge of
$40.00 paid in cash or certified funds. The service charge will increase based upon the number of
disconnections required at the location during the previous six months. A second disconnection with six
months will require a service charge of $60.00. A third disconnection within six months will require a
service charge of $80.00. All disconnected accounts paid after 2:00 p.m. will be reconnected the next
business day.
4. Office hours are 8:00 a.m. to 5 p.m. Monday through Friday. Payments may be made after business
hours in the night deposit box located on the outside of the building directly past the drive-through
window. Timely payments may be made by cash, check, money order or cashier check. We will accept
payment, to be made in person by credit or debit card, using a Visa/MasterCard/ Discover. There will be
a $2.50 convenience charge for this option. You may also make payments at United Community Bank,
or South State Bank, or online at www.SecureUtilities.com. We do not take credit or debit card
payments by telephone.
5. Service may be refused to anyone who has defaulted on payment of any obligation to the City, or has
had service disconnected because of a violation of the rules and regulations of the City.
DEPOSIT INFORMATION
All customers requesting service will pay a $100.00 deposit. This deposit is refundable under the
conditions listed:
a. When water &/or sewer service is discontinued by request of the user, and all outstanding
invoices are paid in full, the security deposit shall be refunded to the user by the City,
provided that the user has given a forwarding address.
b. If service is discontinued for nonpayment of invoices, the security deposit shall be
applied by the City to the outstanding balance. Any remaining balance of the security
deposit shall be refunded to the user; however, if the deposit is not sufficient to pay the
outstanding invoice, the City may proceed with collection of the balance from the user.
c. Any user who enters the meter box and turns on service after service has been cut off
shall be in violation of City ordinances and shall be subject to applicable penalties.
All customers must provide a copy of their driver’s license, and a copy will be made by City office staff
to include in the customer file.