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CITY OF BLACKFOOT UTILITY SERVICE APPLICATION FORM SERVICE ADDRESS BLACKFOOT, ID 83221 OWN HOME RENT BUSINESS PROPERTY MANAGER MULTI-UNIT APPLICANT INFORMATION Name Phone DL Number SS Number Date of Birth Email Employer Name Work Phone Mailing Address (if different than service address) CO-APPLICANT INFORMATION Name Phone DL Number SS Number Date of Birth Email Employer Name Work Phone Mailing Address (if different than service address) BUSINESS ACCOUNT INFORMATION Company Name Federal Tax ID Registered Agent Name Sole proprietorship Corporation Phone LLC Other E-mail Registered company address City, State ZIP Code EMERGENCY CONTACT (Not living in the home) Name Relationship Phone Email Name Relationship Phone Email LANDLORD INFORMATION (IF APPLICABLE) Name Phone ---PAGE BREAK--- I acknowledge receipt of the City of Blackfoot Utility Customer Service Policies & Procedures worksheet. Initial: Final bills are subject to being sent to collections if not paid in full by the due date. In addition, I understand that any cost for collection of past due monies, including attorney fees, collection fees or court costs can and will be charged directly to the customer or added to the customer’s account balance. I understand the City of Blackfoot’s policy regarding delinquent accounts, and agree to the following: If a utility bill falls two months past due, the account will be subject to shut-off Arrangements OR payment of past due bills will be made PRIOR to the shut off day (variable depending upon month) Payment arrangements MUST be completed using the appropriate City form, signed, and submitted to the Utility Billing Clerk in City Hall prior to 8:00 AM on the designated Shut Off Day If I do not make payment arrangements OR make a payment prior to 8:00 AM on the designated Shut Off Day, I agree to pay the full amount owed on my bill, including the delinquent fee(s), regardless of whether services have been shut off. If I do not receive a bill or delinquent bill in the mail, I agree that it is my responsibility to contact City Hall at [PHONE REDACTED], x-1821 or Dial 2 to inquire on the status of my account. The City of Blackfoot is not responsible for delays caused by the US Postal Service. I understand that the signature below is binding and applies to all members who live at the above address. This signature also provides authorization for the City of Blackfoot to deposit ACH funds into my account for any reimbursements. SIGNATURES Applicant Name (Print) Co-Applicant Name (Print) Signature Signature Date Date For Office Use Only / Do Not Write Below This Line Building Safety Signature Date Fire Marshall Signature Date Land Use Signature Date Transfer Balance/Deposit From Deposit Waived Cash Check XBP Receipt Today’s Date Turn On Date Verified Lease (Initial) Verified Deed (initial)