Utility Service Application Form - Village of Winnebago

Type of Utility Service Requested

Service Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone*

Email Address*

Social Security Number

Place of Employment

Identification Provided

Specify

Documentation Provided Evidencing Applicant’s Connection to Service Address

(e.g. Settlement Statement, deed, etc.)

Applicant’s Prior Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Length of time at prior address

Rented or Owned

Please provide name and address of prior landlord

File Upload

Max. file size: 8 MB.

Consent

I hereby acknowledge notice that pursuant to the provisions of Ordinance No. 278, that not only am I liable for payment for the utility services provided on the above premises while the utilities are registered in my name, but also that charges over 40 days past due are declared to be delinquent and thereafter such delinquencies shall constitute liens upon the real estate for which such service is supplied and the Village Clerk is authorized to file sworn statements showing such delinquencies in the Office of the Recorder of Deeds, with the filing of such statements in the pertinent offices deemed as notice for the payment of the charges for such services.

Further, I agree and consent to the utilities at the above-listed address being placed in my name.

I agree.

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Phone

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