Application for Water Service

APPLICATION FOR WATER SERVICE
EXISTING SERVICE
Lakeside, OR 97449
I am requesting water service which is to be billed as follows:
DO YOU OWN OR RENT?
(Confirmation needed prior to obtaining water service)

Primary Applicant

Name
Name
First
Last

Co-Applicant (if any)

Name
Name
First
Last

APPLICATION FEES

Sign-up fee is $100 - $ 25.00 is a nonrefundable new account charge & $75.00 is refundable if the following conditions are met:
a) Your account will be credited $75.00 if bills are made in a timely manner for one consecutive year (on or before the 20th of each month).
b) If you move, you must notify our office to take the water out of your name. We will need your new address so when the final bill is calculated; the remainder of the deposit can be mailed to you.
NEW WATER SERVICE? (NOT INSTALLED)
The undersigned herby applies for a water service inside the District to be installed by the Lakeside Water District
INTENDED USE OF PROPERTY FOR WHICH SERVICE IS APPLIED
Fees are as follows:

System Development Charge: $5,499.00
Meter and Installation: $825.00 minimum*
Application and Deposit: $100.00 (see above)

* If actual cost exceeds this amount, applicant is responsible for the overage costs per ordinance 94-129.

Note: The undersigned prescriber requests the Lakeside Water District to supply water at the premesis noted heron and promises to
purchase the water and pay in accordance with the schedule of rates which shall from time to time be legally in effect for the purpose
for which the water is to be used hereunder, and to confirm to and abide by the rules and regulations in force, relating to the purchase
and sale of water.

TERMS OF AGREEMENT

Drinking water payments are billed on the second to the last business day of each month for the usage starting from the
15th of the second month prior to the 15th of the last month prior. All balances are due and payable by the 20th of the
month. If payment is late, a late fee of 9% of the total balance due per month will be applied to your account.
If the account is not paid by the 20th of the month, a delinquency notice will be sent to the customer notifying them that if
the balance of their account remains unpaid after 10 days, their water service will be turned off. If no payment has been
received in the last 31 days and the account is not paid by the 20th of the month, a door hanger will be placed at the service
address, notifying the customer that water service will be turned off in the next 24 hours.
Service will be restored when 100% of the account balance, including the $85.00 turn on fee, is paid in full.
If a meter is turned off or locked off for nonpayment by the Lakeside Water District, usage is illegal and will incur
additional fee of $400.00 for meter tampering. Meter will then be removed until fee and account balance is paid in full.
There will be a $35.00 fee charged on all returned checks.
If a customer defaults on a previously made payment arrangement, the meter will be turned off and locked off until the
outstanding balance is paid in full.
Collection Fee: If it is necessary to refer this account to a collection agency, you are financially responsible for the
timely payment of your outstanding bill per our payment policies. You will be responsible for any and all collection
agency fees up to 50% of the amount placed with or assigned to, the collection agency. In the event we seek legal action
for collection on your account, you may be responsible for any and all fees associated with court costs, garnishments,
and/or attorney fees. This organization is an equal opportunity provider and employer.
I HAVE READ THE ABOVE STATEMENT AND TERMS

RACE/ETHNICITY/SEX DATA COLLECTION HANDOUT

The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race, ethnicity and sex of applicants on the basis of visual observation or surname.
I DO NOT WISH TO FURNISH THIS INFORMATION
ETHNICITY
RACE: (Mark all that apply)
SEX