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645 Beacon Lite Road, Monument CO 80132 I p: [PHONE REDACTED] I email: [EMAIL REDACTED] Bulk Water Connect Request Date of Application Residential ☐ Commercial ☐ Company Name Contact and Billing Information: Contact Name Mailing Address City State Zip Phone Number Email Address The undersigned hereby requests the Town of Monument to furnish water service to the address designated herein. In exchange for these services, the undersigned agrees to be responsible for all charges for water service, until such time as the undersigned gives proper notification to the Water Billing Department that the services are to be discontinued. In the event the undersigned fails to make a particular payment for water service, the Town of Monument shall immediately become entitled to exercise all creditor remedies for collection of amounts owing, which are allowed by law. The undersigned agrees to pay all costs and attorney fees incurred by the Town of Monument in collection of any amount due. Please note: if an account has no usage for six consecutive six months, the account will be closed, and a new application will be required for any additional usage. • Bulk water meters are read and billed once per month and due by the 20th of the following month • $12.50 late fee charge for payments not received by the 20th of the month • $25.00 insufficient fund charge • Disconnect notice: $20.00 if notice is posted/mailed ☐ Paperless Billing ☐ I agree to the terms, conditions, and restrictions of this application and all applicable requirements related to the use of Town of Monument water pursuant to the Town of Monument Municipal Code, Chapter 13 – Public Services and will maintain the integrity of the water system by leaving the required gap when filling. Bulk Water Customer Signature Date Below for Internal Use Only Account # PIN # Access Code Approved By: Date: