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6/26/2015 TOWN OF MONUMENT BULK WATER CONNECT RESIDENTIAL USE ONLY PLEASE PRINT LEGIBLY DATE NAME CELL PHONE MAILING ADDRESS CITY STATE ZIP CODE E-MAIL IF PREPAID $ CHECK NUMBER DATE SERVICE TO BEGIN PLEASE READ AGREEMENT AND SIGN BELOW: The undersigned hereby requests the Town of Monument to furnish water service to the person designated herein. In exchange for these services, the undersigned agrees to be responsible for all charges for bulk water, until such time as the undersigned gives proper notification to the Department of Water 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 any and all creditor remedies for collection of amounts owing, which are allowed by law. The undersigned agrees to pay all costs and attorney’s fees incurred by the Town of Monument in collection of any amount due. Bulk water is billed once per month and due by the 20th of the following month. A $12.50 late fee will be charged for payments not received by the 20th of the month. There is a $25.00 insufficient fund charge. A $20.00 shut off fee is applied to account IF notice is posted. Your account will be blocked and a shut off charge will be added to your account as follows: $50.00 for the first offense, $100.00 for the second, and $150.00 thereafter. OWNER BULK WATER STATION ADDRESS: 1944 WAGON GAP TRAIL ACCESS PIN # ACCOUNT NUMBER Town of Monument 645 Beacon Lite Road Monument CO 80132 Margo [PHONE REDACTED] [EMAIL REDACTED]