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UTILITY BILLING DEPARTMENT 1049 State Avenue Marysville, WA 98270‐4234 Phone: (360) 363‐8001 Fax: (360) 651‐5175 www.marysvillewa.gov LANDLORD/TENANT STATEMENT FOR UTILITY ACCOUNTS **INCOMPLETE & ILLEGIBLE FORMS WILL BE RETURNED** Account#: Bill run: I, hereby certify that I am the owner/agent of the property located at and that according to City of Marysville Municipal Code 14.05.030, I hereby authorize the City of Marysville to bill the tenant of the above named property for all utility services. I further acknowledge that utility charges represent a lien against the property; therefore, I am ultimately responsible for all utility charges, penalties, and fees on this account. Account balance must be zero before any changes will be made. If tenant has outstanding charges from a previous address with the City of Marysville, we will be unable to put tenant’s name on this account until previous charges are cleared. PLEASE NOTE: Billing your tenant for the above account is a courtesy provided by the City of Maryville. If your tenant’s services are disconnected for nonpayment three times, account will revert to owner name for billing and will remain so as long as that same tenant is in the home. The City reserves the right to put this account back into owner’s name if tenant proves difficult to deal with. Thank you. Owner Signature: Date: _ Owner/Agent printed name: Owner Mailing Address: Phone: Email Tenant Name(s): Phone: Last 4 Digits of SS Drivers License Start Date: (Tenant customer (City will assign) Does this tenant have authority to make payment extensions Yes No up to two weeks beyond shut off date twice per year? (If box not checked, it will default to PLEASE COMPLETE AND RETURN TO: City of Marysville, 1049 State Avenue, Marysville, WA 982704234 THIS FORM MUST BE SIGNED AND RETURNED TO THE CITY BEFORE WE CAN BILL YOUR TENANTS AT THE ABOVE SERVICE ADDRESS