The Town of Double Springs Water & Sewer Board

21 Main Street

P.O. Box 279

Double Springs, Alabama 35553

************SERVICE APPLICATION************

Name: ___________________________________ Date: __________________________

Spouse: __________________________________ Phone #: _______________________

Relative: _________________________________ Phone #: _______________________

Mailing Address: __________________________ Mobile #: ______________________

City,State,Zip: __________________________

Service Address: __________________________

City,State,Zip ___________________________ SS#: ___________________________

EMPLOYER: _____________________________ DOB: __________________________

Address: _________________________________ DL #: __________________________

_________________________________ Work #: ________________________

E-mail address:______________________________________________________

HAVE YOU PREVIOUSLY HAD SERVICE ON OUR WATER SYSTEM? ( ) Yes ( ) No

IS YOUR RESIDENCE OR BUSINESS INSIDE THE CITY LIMITS? ( ) Yes ( ) No

IS THIS A NEW SERVICE OR A TRANSFER SERVICE? ( ) New ( ) Transfer

DATE TO START NEW SERVICE: ___________________

DATE TO STOP SERVICE WHERE YOU ARE TRANSFERING FROM: ___________________

The following information is requested for USDA requirements and is for statistical purposes only:

Race: American Indian/Alaskan Native ⁯ African American ⁯ Asian ⁯ Gender: Male ⁯

Native Hawaiian/Other Pacific Islander ⁯ White Caucasian ⁯ Female ⁯

Ethnicity : Hispanic or Latino ⁯ Other ⁯

I, we, the undersigned and above named applicant hereby request to be supplied with water by the undersigned Double Springs Water & Sewer Board of the City of Double Springs, Alabama, for the purpose shown herein and none other. I, we, agree to pay for the service at regular scheduled rates applicable from time to time as set by Town of Double Springs Water & Sewer Board now or at any future time and to comply with the rules and regulations of the Double Springs Water & Sewer Board of the City of Double Springs, Alabama.

I, we, further agree that:

The Town of Double Springs Water & Sewer Board shall retain title to all meters and other property furnished by it; and

I, we, shall be responsible for the safekeeping of all property of the Water & Sewer Board placed on premises where I, we, receive service; and

I, we, shall guarantee free right of ingress and egress by the Water & Sewer Board employees to meters and other property of the Water & Sewer Board located on the said premises without obstructions (i.e., shrubs, decks, porches, parked vehicles, restrained animals, fences, etc.); and

I, we, will keep in good repair all appliances and piping on said premises (other than meters maintained by the Water & Sewer Board), first notifying the Water & Sewer Board prior to having repairs made, and will report immediately to the Water & Sewer Board any leaks discovered; and

I, we, shall not adjoin a supplementary water service to a new or existing water meter on the Town of Double Springs Water & Sewer Board’s system; and

The Double Springs Water & Sewer Board or the City of Double Springs shall not be

liable for damages because of interruption of the supply of water or by reason of fires,

accidents or any other cause due to or alleged to be due to the installation of service, and

I, we, agree to notify the Water & Sewer Board in person or in writing no less than 72

hrs. prior to vacating said premises or discontinuance of service for any reason; and

The Town of Double Springs Water & Sewer Board shall not refund and payments made by the applicant or property owner, for service pipe from the property line to the meter, unless covered by separate agreement; and

A late penalty of 10% of the current water, sewer, and garbage fees will be added on the delinquent date printed on the utility bill..

Discontinuance of service or referable CUT OFF Procedures, will be as follows:

Any amount past due in excess of $10.00 shall be cut off promptly on the Monday after the 11^th of each month except in special circumstances (i.e., holiday, etc.)

Cut offs will be performed Monday through Friday of each week, when deemed necessary; and

A reconnection fee of $50.00 will be charged to reinstate service; and

(d.) The account must be paid in full plus the reconnection fee before service will be

reinstated; and

Meter Readers are not allowed to collect payments in the field, unless authorized by management; and

A meter reader must disconnect all accounts that have a notice; and

If a reconnection occurs after hours, there will be an additional $50.00 call out fee.

The undersigned agrees to be liable for, pay, or reimburse the Town of Double Springs Water & Sewer Board for all costs and expenses, including, but not limited to reasonable attorney’s fees, annual percentage rate of 18% interest, incurred by the Town of Double Springs Water & Sewer Board in collecting or attempting to collect any sum due by the undersigned to the Town of Double Springs Water & Sewer Board for water and/or otherwise; and I waive all my rights of exemption as to personal property under the constitution and laws of the State of Alabama or any other state; and

The Town of Double Springs Water & Sewer Board shall have the right to discontinue service without further notice in case of the applicants failure to comply with this agreement or any part thereof, I, we, agree that any unpaid balance(s) on established account for services rendered, will be paid promptly at time service is discontinued.

The Town of Double Springs Water & Sewer Board does not discriminate

on the basis of race, color, national origin, gender, religion, age, disability,

political beliefs, sexual orientation, and marital or family status.

This institution is an equal opportunity provider.

Customer Signature:_______________________ Date:_______________