Billing Agreement Step 1 of 3 33% Effective Date* Account NumberPrevious Owner First Last Property Location*Your Name* First Last Mailing Address* Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email* Type of Service*ResidentialCommercialSocial Security or Driver's License #*Fed ID #Date of Birth* Place of Employment or Source of Income*Do you owe any outstanding bills for water?*YesNoDo you owe any outstanding utility bills of any kind?*YesNoHave you filed for bankruptcy within the past 6 years?*YesNoAnnual or Seasonal?*ANNUAL: Year round water service at the same premise. (Quarterly Billing)SEASONAL: Seasonal water use includes intermittent use, season after season, at the same premises. (Seasonal Billing)Percentage Used for Business*Please specify the percentage the property is used for Business purposes. This is for Maine State Bureau of Taxation. All water used for business purposes is taxable. If not completed, Commercial property will be taxed at 100% Must be broken down to nearest 10%Percentage Used for Personal*Please specify the percentage the property is used for Business purposes. This is for Maine State Bureau of Taxation. All water used for business purposes is taxable. If not completed, Commercial property will be taxed at 100% Must be broken down to nearest 10%IMPORTANT* I hereby contract with Boothbay Region Water District for water service and agree to pay for the same in accordance with the established rates of said Water District until written notice is given to discontinue said water service, and to conform to all Rules and Regulations of said Water District, now in force or which may hereafter be adopted, governing the use of water. I understand that should my property ever be rented, and the tenant has water service in their name(s) and fails to make full payment I, as the property owner, am responsible for payment and agree to indemnify and hold harmless the Boothbay Region Water District from any and all debts and costs of collection in connection with said debt. Please Type Your Full Name to Serve as Electronic Signature* Credit Reference FormFull Applicant Name* First Middle Last Full Co-Applicant Name First Middle Last Mailing Address* Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Phone Number*Legal Residence (Physical Location)*Credit References (Businesses you have had credit with. Example: Electric Company, Fuel Company, Landlord.)Credit Reference Name* First Last Contact Number*Credit Reference Name* First Last Contact Number*Credit Reference Name* First Last Contact Number*Release* I/We hereby give the Boothbay Region Water District permission to release any and all information which may be deemed necessary in order for collection of any outstanding debts I/We may occur to the Water District. Applicant: Please Type Your Full Name to Serve as Electronic Signature*Co-Applicant: Please Type Your Full Name to Serve as Electronic Signature Civil Rights Information Collection for USDA Financed Organizations USDA financed facilities that use applications to determine eligibility for receipt of benefits or services or for informational purposes, will put the slogan "Equal Opportunity Program" on the bottom of their application forms and informational brochures. Recipients using application forms shall establish a section at the end of the form, below the signature and date block or a separate card/sheet to collect race/national origin information. In addition, the following disclosure notice shall be included "The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/nationality origin of individual applicants on the basis of visual observation or surname.Race:* White Black Hispanic American Indian or Alaskan Native Asian or Pacific Islander I prefer not to answer Sex*MaleFemaleI prefer not to answer Recipients using application forms will provide services and benefits in the order applications are received. A current waiting list will be maintained by the date and time an application is received, name of the applicant, race/national origin and a summary of the action taken Above records will also reflect the number of applicants approved or rejected for the benefit or service by race/national origin. The recipient shall make a report of this information available to Rural Development employees, USDA officials, and other appropriate Federal employees, i.e., HUD or DOJ employees, as requested by telephone or written notice through an appropriate Rural Development Official.
