DATE______________

 

WATER:  $20.00                                 ELECTRIC:  $35.00

 

CASH_______________                    CHECK NO__________________

 

Accepted for the City by___________________________

 

I/We, the undersigned, do hereby agree to be responsible to the City of Beloit, Kansas, at the Utilities Office of said City, for all utility services, provided to the address for service as shown below, beginning on this date of __________________.  I further agree to comply with all provisions of the City Ordinances.  I further state that I am not as of this date, in arrears to the City of Beloit for any previous utility bills.  I also understand that the connect fees charged is a NON-REFUNDABLE Service connect fee.

 

 

 

______________________________      ____________________________________

Utility Service Address                                Billing Address

 

 

______________________________      ____________________________________

Occupant/or Occupants                             Social Security Number/Daytime Phone

 

 

______________________________      ____________________________________

Occupant/or Occupants                             Social Security Number/Daytime Phone

 

 

______________________________      ____________________________________

Occupant/or Occupants                             Social Security Number/Daytime Phone

 

 

______________________________      ____________________________________

Property Owner/or Owners                        Utility Payment Policy Letter Given