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CITY OF MARYSVILLE UTILITY BILLING 501 Delta Ave Marysville, Washington 98270-4234 Phone (360) 363-8001 Fax (360) 651-5175 www.marysvillewa.gov LANDLORD/TENANT STATEMENT FOR UTILITY ACCOUNTS Service Address: City: Account Number: Owner/Agent Name: Phone Number: Last four digits of SSN (owner): Driver’s License (Owner): Owner/Agent Mailing Address (include city, state, zip): Email Address: Fax Number: I hereby certify that I am the owner/agent of the above named property and that according to City of Marysville Municipal Code 14.05.030 I hereby authorize the City of Marysville to bill the tenant of said 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. Owner/Agent Signature: Date: Move-in Date: Tenant Name Last four digits of SSN: Driver’s License: Phone Number: Email Address: Tenant Name Last four digits of SSN: Driver’s License: Phone Number: Does this tenant have authority to make payment extensions up to two weeks beyond the shut off date, three times per year? (if box not checked, it will default to “No”) Yes No Billing your tenant for utilities is a courtesy provided by the City of Marysville. If your tenant’s services are disconnected for nonpayment three times, the account will revert to the owner 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 the tenant proves difficult to deal with. All accounts, including previous tenant’s accounts, must be paid in full and closed before a new tenant will be added to the account. The responsibility of the owner/agent is to notify the City as soon as a tenant moves out or moves in to ensure appropriate billing to the correct party. If the City is not notified as to when a tenant has moved out, the account will revert back to the owner based on the information the City has and it will be the responsibility of the owner/agent to pay the appropriate balance on the account. Please print clearly. Incomplete or illegible forms will not be accepted and will be returned. Return completed forms to City Hall via fax, email [EMAIL REDACTED], mail or drop off in person. Tenant information section to be completed by Owner/Agent only Interoffice Use Only: Notes: CID: Bill Run: Date Stamp and Initial