New Svc Residential App Revised0112 by D5D29A5

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									                                 WINSTON-DILLARD WATER DISTRICT
                                    WATER SERVICE APPLICATION
                                 121 NW Douglas Blvd. Winston, OR 97496 PHONE: 541-679-8467 FAX: 541-679-4875

                          WINSTON-DILLARD WATER DISTRICT IS AN EQUAL OPPORTUNITY PROVIDER.

TODAYS DATE:                               DATE ON:                                     ACCOUNT #:

    OWN / RENT             $25.00 SERVICE FEE   □     $50.00 DEPOSIT     □     NO FEE     □               NAME CHANGE / LANDLORD

                                                                                                     EMPLOYER
APPLICANT:                                                    EMP:                                   PHONE#:

SOCIAL SECURITY #:                                            DOB:                                   ODL:
(Voluntary Information)

                                                                                                     EMPLOYER
CO-APPLICANT:                                                 EMP:                                   PHONE#:

SOCIAL SECURITY #:                                            DOB:                                   ODL:
(Voluntary Information)

                                                                                                     HOME
SERVICE ADDRESS:                                                                                     PHONE#:


MAILING ADDRESS:                                              CITY, STATE, ZIP:

PROPERTY OWNER:                                                                                      PHONE #:

EMERGENCY CONTACT:                                                                                   PHONE #:

CO-APPLICANT SIGNATURE :

APPLICANT SIGNATURE:                                                                                 EMPLOYEE INITIALS:

                                        TRANSFER ~ MOVING WITHIN DISTRICT
DATE:                                                                                   ACCOUNT #:

DISCONNECT DATE OF OLD ADDRESS:                                                         DATE OF NEW CONNECT:

NEW SERVICE ADDRESS:                                                                    CITY, STATE, ZIP:

NEW MAILING ADDRESS:                                                                    CITY, STATE, ZIP:

PROPERTY OWNER:                                                                         PHONE #:

REQUESTED BY:                                                                           PHONE #:

CUSTOMER SIGNATURE:                                                                     EMPLOYEE INITIALS:

                                                    SERVICE TERMINATION
REQUESTED BY:                                                                           DATE OF DISCONNECT:

FORWARDING ADDRESS:                                                                     PHONE #:

CITY, STATE, ZIP:

CUSTOMER SIGNATURE:                                                                     EMPLOYEE INITIALS:




                                                                                                                    Revised 10/4/2012
                                                   WINSTON-DILLARD WATER DISTRICT
                                                          DISTRICT POLICIES
                                                                       RESIDENTIAL RATE
                       121 NW DOUGLAS BLVD., WINSTON, OR 97496                                             PHONE: 541-679-8467   FAX: 541



The applicant, hereinafter designated "Customer", makes application for domestic water service at an existing water conne
with all rules and regulations of the WINSTON-DILLARD WATER DISTRICT.
It is understood that water service is to be supplied by the District and accepted by the Customer subject to the District's te
schedules of change duly adopted and now in force or as amended by action of the Board of Commissioners of the Distric
District, or its authorized officers and agents, will not be liable for delays in the furnishing and delivery of water to the cus

Customer agrees to pay a $25.00 non-refundable New Service Fee required to set the account up, and an additional $50.00
when the account is terminated and the final account balance is deducted. The $50.00 deposit does not accrue interest. Th
for any water damage caused by turning service on at an address where fixtures, hoses or appliances, etc. have been left o
The District reserves the right to cancel this application and the service agreement at any time for cause.




                                                                     SCHEDULE OF WATER RATES

BASE RATE -Per Dwelling                   INSIDE DISTRICT        Out of District   MISCELLANEOUS RATES / FEES
0 to 4,000 GALLONS                             $32.50                $65.00        DEPOSIT
4,001 to 25,000 GALLONS                  $2.65 PER 1,000 GAL                       NEW SERVICE FEE
25,001 to 50,000 GALLONS                 $2.95 PER 1,000 GAL                       NSF FEE
50,001 to 100,000 GALLONS                $3.45 PER 1,000 GAL                       NON PAY FEE
100,001 ~ OVER                           $4.45 PER 1,000 GAL                       LATE PAYMENT FEE
                                                                                   RECONNECT FEE
                                                                                   LANDLORD SERVICE FEE
THERE IS NO VACANCY RATE.
                                                                 RATES EFFECTIVE AS OF JANUARY 1st, 2012



Meters are read each month starting around the 15th and bills are mailed on the last working day of each month. Bills are
delinquent if payment is not received in the office by the 25th of the month. A $5.00 late fee will be assessed on all unpaid
pay shut off notices are issued the 25th of the month and payments or payment arrangements need to be made or water w
Wednesday of the following month. A Non-pay Shut off Fee of $50.00 will be assessed and due before water service is rec
for non-payment will not be restored until after 2:00 PM on the day of shut off. THIS INSTITUTE IS AN EQUAL OPPOR



Please notify the office in person if you are moving to disconnect your service. Your name will remain on the account and
water charges until we are notified otherwise. In the event this account is forwarded to Credit Services of Oregon for colle
40% collection fee as allowed by OREGON LAW to the outstanding balance.

CO-APPLICANT SIGNATURE:
APPLICANT SIGNATURE:                                                               EMPLOYEE INITIALS:




  Updated 01/01/2012
LLARD WATER DISTRICT
TRICT POLICIES
 SIDENTIAL RATE
                                   PHONE: 541-679-8467   FAX: 541-679-4875



on for domestic water service at an existing water connection and agrees to comply
 DISTRICT.
and accepted by the Customer subject to the District's terms, regulation and
 by action of the Board of Commissioners of the District as provided by law. The
delays in the furnishing and delivery of water to the customer.

 equired to set the account up, and an additional $50.00 deposit that is refundable
ducted. The $50.00 deposit does not accrue interest. The District is not responsible
where fixtures, hoses or appliances, etc. have been left on by previous occupants.
 vice agreement at any time for cause.




 DULE OF WATER RATES
          MISCELLANEOUS RATES / FEES
                                                                                 $50.00
                                                                                 $25.00
                                                                                 $30.00
                                                                                 $50.00
                                                                                  $5.00
                                                                                 $25.00
                                                                                 $10.00


 ECTIVE AS OF JANUARY 1st, 2012



mailed on the last working day of each month. Bills are due upon receipt and are
e month. A $5.00 late fee will be assessed on all unpaid accounts on the 26th. Non-
 or payment arrangements need to be made or water will be shut off on the second
 .00 will be assessed and due before water service is reconnected. All water shut off
  of shut off. THIS INSTITUTE IS AN EQUAL OPPORTUNITY PROVIDER.



our service. Your name will remain on the account and you will be responsible for
ount is forwarded to Credit Services of Oregon for collection activity, we will add a
g balance.



          EMPLOYEE INITIALS:




              Updated 01/01/2012

								
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