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2. 
4. Section 1: New Business Account Holder Information

   Please provide full contact information for the individual that the account will be opened under.

6. Date for Service to Commence*
   Date for Service to Commence
8. Business Name*
9. Federal Employer Identification Number (FEIN)*
11. Service Address*
13. Mailing/Billing Address (if different from service address)*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Accounts Payable Contact
22. E-mail Address*
26. Is this property a rental?*

    1. Yes
    2. No

    If yes, please fill out the information below. If no, proceed to Section 3.
28. Rental Property Information
    If the service property is leased, please provide the landlord’s contact information below. Please be aware if you lease, your landlord will be notified if you are delinquent on your account per Ordinance #864. If you are the landlord, and you require your tenant to be responsible for payment, a copy of the Village of Elwood’s Landlord/Tenant policy is available for your review upon request.
30. Indicate Your Status

    1. Tennant
    2. Landlord
31. Indicate Responsible Party for Utility Bill

    1. Tennant
    2. Landlord
33. Landlord's Name
34. Landlord's Phone Number
36. Landlord's Address
38. City
39. State
40. Zip Code
44. Section 3: Authorization for Account Discussion
    Authorize the appropriate individuals to discuss personal and sensitive information in regards to your Utility account.
46. Would you like to authorize anyone other than yourself to discuss confidential information about your account?*

    1. Yes
    2. No

    If yes, please fill out the information below. If no, proceed to Section 4.
48. Authorization for Account Discussion Information
    Due to the ‘Fair Debt Collection Protection Act,’ the Village of Elwood is unable to communicate with anyone other than the individual listed on the account. This means we are unable to discuss balances, payment arrangements or any other personal and confidential matters with anyone but the account holder. The ‘account holder’ is defined as the person who the monthly bill is addressed to. If you would like someone else to be able to discuss your account with the Village of Elwood, we must have that person listed on your account as an authorized person. Please fill out the form below for required authorization.
50. I hereby give the following individual(s) permission to discuss my account with the Village of Elwood:
52. Name
53. Phone Number
55. Name
56. Phone Number
58. Name
59. Phone Number
63. Section 4: Review, Submit Attachments and Indicate Payment
    Double check your form and add any necessary attachments.
65. Indicate Payment Method*

    1. Check
    2. Credit Card
    3. Cash

    Opening a utility account requires a deposit of $150.00. Payment can be made in person at the Village Hall, Water Payment DropBox, or online by following the link below.

    Utility Bill Pay

69. Section 5: Terms & Conditions of Utility Billing
    Listed below you will find the terms and conditions of the Village of Elwood in regards to the water, sewer and garbage utility billing collection procedures. Please read and understand the policies.
71. Payment Due Date*

    1. I understand the below statement.

    All payments are due on or before the 5th of the month.
73. Rates - Effective May 1, 2021 - April 30, 2022*

    1. I understand the below statement.

    Water: $33.72 for the first 2,000 gallons, and $4.62 for every 1,000 gallons after that. Sewer: $20.28 for the first 2,000 gallons, and $4.67 for every 1,000 gallons after that. Garbage: $24.87 per month.

75. Fees*

    1. I understand the below statement.

    Late Fees: 10% charge are applied on the 6th of the month for past due balances. Returned Check Fee: $25.00 per check that is returned. Water Re-connection Fee: $75.00 by request of the account holder or the Village due to past due accounts. Collection Costs: 30% fee added to outstanding balance if turned over to a collection agency. Administrative, legal, and court costs: $41.00 for recording a lien plus additional charges as determined by legal counsel and the Village administration.

77. Collection Procedures Outlined:*

    1. I understand the below statements regarding the collection procedures.
79. Past Due:
    If payment is not received by the due date, a 10% penalty will be applied.
81. 10 Days Past Due:
    Utility bills are considered delinquent if payment has not been received within 10 days after the due date. If your account becomes delinquent, a notice will be sent, it will include the past due charges, 10% penalty and notice that water will be disconnected if payment in full is not received within 5 days.
83. 15 Days Past Due:
    No additional notice will be sent. If payment of delinquent charges is not received, Public Works will be notified to disconnect water service. If disconnected by the Village, the delinquent amount plus a $75.00 reconnect fee must be paid before service will be turned back on. In hardship cases, a payment agreement must be made in advance and approved by the Utility Billing Clerk. It is unlawful to turn water supply that has been disconnected for failure to pay, violations will be prosecuted. Restoration of discontinued service will be in accordance with and subject to, the fees and deposits required under the current Village ordinance, just as a new customer account. In addition, water that has been disconnected will not be turned on outside of regular Village business hours of 7:00 am to 1:00 pm.
85. Exceptions to Past Due Regulations:
    If a customer has had pervious payment issues or the water has been shut off previously due to a delinquent account, the water will not be turned back on until the account is paid in full along with the $75.00 reconnection fee.
87. Signature and Authorization
    By signing below, I am confirming that all information provided is valid to the best of my knowledge and I agree to all terms and conditions as outlined above. I also understand that at the time I vacate the above listed property, I will notify the Village of Elwood thirty (30) days prior to my vacancy by filling our a utility account termination form for final billing. I understand that my deposit of $150.00 will be refunded within thirty (30) business days of my termination date and any outstanding balances on my account will be deducted from the said deposit.
89. Electronic Signature*
    By providing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
90. Date*
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit Submit and Print

* indicates a required field