Action Center / WMU Utilities Activation Form (Residential) / Washington, IN

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WMU Utilities Activation Form (Residential)

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Form for residential utility hookup

* Denotes a required field

Residential Utilities Activation Form

First Name

Middle Initial

Last Name

Driver's License Number

Social Security Number

SSN 1-SSN 2-SSN 3

Date of Birth

Telephone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Email Address

Employer

Spouse's Name

Maiden Name or Alias

Spouse's Driver's License Number

Spouse's SSN

SSN 1-SSN 2-SSN 3

Spouse's Date of Birth

Spouse's Telephone Number

Phone Area Code-Phone 3-Phone 4 ext Extension

Spouse's Employer

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

City

State

Zip Code

Zip-Zip +4
Second portion of ZIP Code is optional.

Billing Address (if different from above)

Billing Address City

Billing Address State

Billing Address Zip Code

Zip-Zip +4
Second portion of ZIP Code is optional.

How many persons will occupy this address?

List names of all parties aged 18 and over to occupy this address

Please Do Not Complete The Following Field

Are you renting at this address? (If renting, you must attach copy of lease)

Yes No

Property Owner/Manager

Emergency contact name

Emergency contact telephone number

Requested Date of Service Connection

MonthDay Year,

Utilities Requested

Electric

Water

Sewer

City trash pickup

Security Question/Answer

Washington Municipal Utilities has my permission to release information about my account to the following persons/agencies: (We cannot give information about your account to anyone without your permission. This includes family members, landlords, charitable agencies, etc.)

I have read through the above information and duly attest that the above responses are true. I understand that misrepresentation or omission of any facts or information called for on this application is subject to any and all City of Washington codes and/or ordinances. I understand that if such information is found to be false (fraudulent), the City of Washington will be bound to resolve this matter in accordance to its policies, codes, and/or ordinances, which may include any necessary fees or fines.

Signature*

The City of Washington, Indiana

Small City... Big Possibilities

WMU Utilities Activation Form (Residential)

Residential Utilities Activation Form

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