Utility Service Application

1. Applicant Information

Name(s)

Service Address

Mailing Address (if different)

Phone Number

Own or Rent

Own

Rent

2. Services Requested (check all that apply)

Services Requested

Water

Sewer

Sanitation

3. Deposit Required – $110.00

Refundable per Village Utility Billing Policy. Payment due upon application.

4. Start of Service Date

Requested Start Date

5. Applicant Agreement

By signing below, I acknowledge that I have received, read, and agree to comply with the Village of Sugar Grove Utility Billing Policy and Procedures. I understand that utility service is subject to the rules adopted by the Board of Public Affairs and the Ohio Revised Code. I also acknowledge that a valid driver’s license or state-issued photo ID must be presented at the time of application.

Applicant SignatureType your full name to sign, or sign the printed copy.

Date

If renting: Property Owner SignatureType your full name to sign, or sign the printed copy.

Property Owner Signature Date

6. Office Use Only

Location Number

Account Number

Deposit Received

Yes

Amount: $110.00

Date Received

Meter Number

Initial Read

Entered by

Office Date

Submission Instructions

Submit this completed application with the $110.00 deposit and a valid driver’s license or state-issued ID to the Village of Sugar Grove Fiscal Officer. Applications may be submitted in person at the Municipal Building or by email at shaley@sugar-grove.com. Payment must be received before service will be activated.

Submit via Email opens your email program with your answers filled in. A signed form, photo ID, attachments or payment still need to be delivered as the form says.