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CITY OF BLACKFOOT LANDLORD AGREEMENT SERVICE ADDRESS BLACKFOOT, ID 83221 HOME BUSINESS MULTI-UNIT OWNER/LANDLORD INFORMATION Name Co-Owner (if applicable) SS Number SS Number Phone Phone Email Mailing Address (if different than service address) PROPERTY MANAGER INFORMATION (IF DIFFERENT FROM OWNER/LANDLORD) Name Phone Mobile Fax Email 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 ---PAGE BREAK--- I acknowledge receipt of the City of Blackfoot Utility Customer Service Policies & Procedures handbook. Initial: As owner or manager of the property(ies) listed, I hereby authorize the City of Blackfoot to place the account(s) in my name during times of vacancy, or at all other times when a tenant(s) name has not been provided I agree to pay for all utilities provided to the property(ies) listed on this agreement while in my name. In the event of the service being disconnected for nonpayment while the service is in my name, all delinquent amounts, in addition to a $50.00 delinquent fee, are to be paid in full before services will be restored. Failure to comply will result in the immediate cancellation of this Landlord Agreement. I authorize the City of Blackfoot to disconnect the utilities of my tenant(s) if the City deems it necessary. I further agree that I will not hold the City of Blackfoot liable for any damages incurred should the City of Blackfoot need to discontinue services during routine collections. I understand that the City of Blackfoot will NOT notify me of the disconnection. I will notify the City of Blackfoot for reconnection of services. 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 individuals who own or manage properties identified on this Agreement. This signature also provides authorization for the City of Blackfoot to deposit ACH funds into my account for any reimbursements. SIGNATURES Owner Name (Print) Co-Owner Name (Print) Signature Signature Date Date For Office Use Only / Do Not Write Below This Line Safety/Fire Approval Signature Date Land Use Approval Signature Date Transfer Balance/Deposit From Deposit Waived Cash Check XBP Receipt Today’s Date Turn On Date Verified Lease (Initial) Verified Deed (initial)