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City of Oldsmar Reclaimed Water Connection Fee Installment Agreement

  1. ____________________________________________
    Customer Name
  2. ____________________________________________
    Service Address
  3. ____________________________________________
    Email
  4. ____________________________________________
    Date
  5. ____________________________________________
    Number
  6. Total Amount Due $320
  7. Utility Billing Use
  8. ____________________________________________
    Location Code
  9. ____________________________________________
    UB Account No.
  10. ____________________________________________
    Accepted By
  11. ____________________________________________
    Name of Applicant
  12. I ________________________________________________________ acknowledge the above amount to be due for the Reclaimed Water Connection fee. I also agree to have this fee added to my utility bill in monthly installments as indicated below:
  13. OPTIONS (select one):
  14. Check if you understand and if applicable to you
  15. The monthly installments will commence the billing cycle following acceptance of this application and continue each month until the $320 reclaimed water connection fee has been paid in full.
  16. ____________________________________________________________________________________________________________________________________
    Comments
  17. ____________________________________________
    Customer Printed Name
  18. ____________________________________________
    Customer Signature
  19. ____________________________________________
    Date
  20. Leave This Blank: