Temp/Perm Power Set Up Form

Temporary/Permanent Power Application

WARNING: When filling out this form please do not hit your browsers BACK BUTTON. All of the information that you have entered will be lost!

You should only use this form if you are constructing a new building. If you need to setup utilities on an existing building, home, apartment, etc. please do not use this application.

Set Up Date*

Legal Name of Business*

Business EIN #

Business Type*

If Other list Business Type Here:*

Guarantor's Name*

First NameLast Name

Guarantor's Social Security Number*

Service Address*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Used to contact you to confirm your account has been set up*

Area CodePhone Number

Guarantor's E-mail*

Would you like anyone else (i.e. Accounts Payable Clerk, etc.) to be able to make inquiries & changes to your utility account?*

If you answer "Yes" to this question the Authorized Employee Information Section must be completed below.

Authorized Individual (Account info can only be given to individuals listed on this application)*

First NameLast Name

Authorized Individual - Last 4 digits of Social Security #*

This information may be required to be given to a Spanish Fork City employee to verify identity when an authorized individual make inquiries and/or changes to account.

Authorized Individual - Phone Number*

Authorized Individual - E-mail*

SPANISH FORK CITY, a Municipal Corportation of the State of Utah and Guarantor/Business as indicated above hereinafter CUSTOMER

1. City will provide the following services to CUSTOMER at the service address previously indicated on this Utility Contract: Mandatory Services Gerneral Service Electric, Pressurized Irrigation (may be exceptions), Business Water, & Business Sewer.

Services shall be provided in accordance with State law and municipal ordinances and resolutions as requested on the setup form at rates as established by ordinance or resolution of the Spanish Fork City Council provided that CITY shall not be responsible for failure to deliver services by reason of strikes, accidents, acts of God, weather conditions, natural disasters - whether declared or undeclared, state or other governmental regulations or any other act, contingency of bar beyond CITY's control.

2. CUSTOMER shall pay such fees and deposits as shall be established by the city and shall further be subject to termination of services upon non-payment or failure to comply with rules, regulations, ordinances or laws as established by the city. CUSTOMER acknowledges and agrees to pay charges for the sewer bond, minimum water charges, and minimum electric charges, even in the event that the premises are vacant for extended periods of time, provided that CUSTOMER may eliminate minimum electric charges only by requesting the CITY to terminate service. In such event, CUSTOMER agrees to pay a reinstatement fee, as set by the city council, to restore electric power service. Utility deposit will be determined by estimated electric consumption. It will be held for an indefinite period of time without interest. However, if all payments are made on time and in full for thirty-six (36) months, deposit will be refunded upon request. Customer agrees to be bound by the utility policy of the CITY and to pay applicable rates as established by the city council. Customer also agrees to the terms and conditions of the CITY’s rate schedule. In the event payment is late, a 5% late fee will be assessed. There will be a charge on all returned checks in the maximum amount allowed by state law, and CUSTOMER agrees to pay the same. Utility service is subject to city ordinances and policies established by the Spanish Fork City Council.

3. The City requires free unobstructed access to electric, water and pressurized irrigation meters at all times.

4. GUARANTOR does hereby agree and is hereby bound and is equally liable with CUSTOMER to pay the CITY any amounts billed pursuant to this agreement.

5. In the event this account is placed with an attorney for collection, either with or without suit, CUSTOMER and GUARANTOR shall be responsible for all court costs and reasonable attorney's fees incurred thereby.

6. In the event this account is placed with a collection agency for collection, CUSTOMER shall be responsible for all collection costs incurred including a collection fee of up to 40%, pursuant to the provisions of Utah Code Ann. §12-1-11.

7. CUSTOMER and GUARANTOR, if any, hereby warrant and affirm that the information provided on the hereof set up form is true and correct to the best of their knowledge. FAILURE TO PROVIDE TRUE AND ACCURATE INFORMATION MAY SUBJECT YOU TO CRIMINAL PROSECUTION UNDER UTAH CODE S76-8-504. CUSTOMER and GUARANTOR also affirm, understand, and agree to comply with provisions of this utility contract.

8. Federal law requires that we establish your identity, either by accessing information in your credit report, or by viewing an acceptable form of picture identification as outlined in our identity theft prevention policy. By submitting this application you are authorizing us to obtain information from your credit report to validate your identity.

Applicant Signature*

Clear

Date Signed - Applicant*

Security Question*

To verify your identity when making future inquiries about your account the answer to a Security Question may be required.

Security Question Answer*

Would you like to enroll in Autopay?*

Authorization Agreement

I hereby authorize Spanish Fork City Corp. to initiate automatic withdrawals from my account at the financial institution named below. I understand that payment will be deducted from my account on the due date of each month or the following business day if the due date is on a weekend or holiday.

I understand that I am responsible to pay a returned item fee as specified by the City for any automatic debit that is returned to Spanish Fork City for any reason. In addition, I understand that I will be removed from automatic withdrawals and that a $200 deposit will be required.

Further, I agree not to hold Spanish Fork City Corp. responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in withdrawing funds from my account.

This agreement will remain in effect until Spanish Fork City Corp. receives a written notice of cancellation from me or my financial institution, or until I submit a new/updated ACH Autopay form to Spanish Fork City.

I understand that if I make a payment using another payment method (i.e. in office with cash or check or online with a card) after the 15th of the month, my automatic payment may still be deducted on the due date by Spanish Fork City and I assume responsibility for any bank/credit union fees that may result.

Type of Account*

CheckingSavings

Name of Financial Institution*

Routing Number*

Account Number*

Routing Number: first 9 digits

Account Number: digits in between the routing

number and the check number

Signature - Authorization to Sign Up for Autopay*

Clear

Date Signed*

( ) Created Out

( ) Saved New Application

( ) Verify Signature on Application

( ) Reviewed

( ) Payment Received

( ) Verified SS #

( ) Contacted Customer

( ) Setup in Caselle

( ) Reviewed Caselle Setup

( ) Saved to Final Destination

Building Inspector

Approval ___________ Date ________ Time _______ Contacted________

Electric

Date ________ Reading _____________ Ser. #________ERT#_______

Power Multiplier ______________ Power Demand(Y/N)? _________

Authorized Individual Information

Spanish Fork City - Business - Utilities Contract

Customer Authorization for Autopay