CITY OF SUMMERVILLE APPLICATION FOR UTILITY SERVICE

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1 APPLICATION FOR UTILITY SERVICE Water Deposit Paid Gas Deposit Paid Receipt # by (For Customer Service Representative use) Applications are processed on a first come first serve basis and will be processed before the end of the next business day. APPLICANTS - PLEASE PRINT *NAME: FIRST MIDDLE LAST DATE: CONTACT PHONE NUMBER: DRIVER LICENSE NUMBER: SOCIAL SECURITY NUMBER: ADDRESS: MAILING ADDRESS: (Where you want utility service to be turned on) (If you want your bill mailed to a location other than where you are turning on utility service.) PERSONAL IDENTIFICATION AND RENTAL/OWNERSHIP DOCUMENTATION REQUIRED. FALSE STATEMENT OR INCORRECT INFORMATION LISTED COULD RESULT IN NO SERVICE OR DISCONNECTION. Utility Service Required: Water Natural Gas Date & Time Application filled out: Date Location Category: Residential Business Time: The following information is requested by the Federal Government in order to monitor compliance with Federal Law prohibiting discrimination against applicants seeking to participate in the program. You are not required to fumish 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 fumish it, we are required to note the race/national origin of individual applicants on the basis of visual observations or surname. _ White, not of Hispanic origin _ Black, not of Hispanic origin American Indian or Alaskan native _ Hispanic _ Asian or Paci fic Islander This is an Equal Opportunity Program. Discrimination is prohibited by Federal law. Complaints of discrimination may be filed with the Secretary of Agriculture, Washington, DC

2 PAGE 2 UTILITY SERVICE APPLICATION Do you own or rent the property where you are getting service turned on? _Own Rent If you rent please list the landlord's name and contact telephone number: Name: Phone Number: Have you ever had utility service with the City of Summerville before: Yes No If "Yes" please list the name, address, and year of your prior service with us: Name: Address: Year: Name of your LAST WATER OR NATURAL GAS SUPPLIER: YOUR EMPLOYER: Employer's Address: Phone: Name of any person you authorize to have access to your account information and their relationship to you. Name: Relationship: Do you authorize this person to make arrangements or changes to your utility account? Yes or No Payment for services issued is the sole responsibility of the individual listed as the account owner. Authorizing someone to have access to your account does not relinquish your responsibility or alter your obligation to meet payment requirements. DEPOSIT REQUIREMENTS: All new customers are required to establish a utility security deposit for each type of utility service requested. Security deposits are applied to a customer's utility account after 12 months of on-time payments with no late payment penalties or returned check payments. Security deposits are not retained in an interest bearing account for customers. DISCONNECTION POLICY: Non-payment is considered to be any account balance $20.00 or more that is unpaid 20 days past the original due date. Customers are disconnected for nonpayment of a utility account and/or a check issued to the City of Summerville which is not honored by the issuing bank; commonly called a "returned" or "bounced" check. Disconnected customers will be required to establish a tiered security deposit directly related to the number of times the customer has been involuntarily disconnected. Once service is disconnected for nonpayment reconnection of the service(s) will require payment of the full balance on the utility account at the time of reconnection, $50.00 reconnect fee PER UTILITY SERVICE, and upgrade of the security deposit based on the account history. Reconnection of account(s) associated with returned check(s) must pay a $35.00 returned check service fee per check, the face value of the returned check(s), $50.00 reconnection fee per utility service, and an upgrade of the security deposit(s) based on the account history. Checks are NOT accepted for restoration of utility service(s) disconnected due to returned check(s). The City of Summerville will mark an account as "NO CHECKS ACCEPTED" if a second check is returned within six months of the first occurrence. The "NO CHECKS ACCEPTED" status shall remain in place for 12 calendar months from the second occurrence. The City of Summerville will mark an account as "NO CHECKS ACCEPTED" if an account has pre-paid a second check within six months of the first occurrence. The status of "NO CHECKS ACCEPTED" status for repeat pre-paid check(s) will remain in place for 12 calendar months from the date of the second occurrence.

3 PAGE 3 UTILITY SERVICE APPLICATION DISCONNECTION POLICY CONTINUED: The City of Summerville does not disconnect natural gas service between November 15 and March 15 if the local temperature is forecasted to be below 32-degrees Fahrenheit for the ensuing 24-hour period. Payments made for utility service by check subsequently returned to the City of Summerville as an unacceptable tender will result in all utility service being immediately disconnected. RESIDENTIAL Initial Water Deposit $ Second Water Disconnection Deposit Upgrade Requirement Third Water Disconnection Deposit Upgrade Requirement $ $ Initial Gas Deposit $ Second Gas Disconnection Deposit Upgrade Requirement $ Third Gas Disconnection Deposit Upgrade Requirement $ All charges/fees subject to change upon authorization of City Council. PRIOR ACCOUNTS: Any prior City of Summerville utility account with an outstanding balance not divulged or discovered at the time this application is completed and confirmed as yours will be transferred to your "new" account. PAYMENT METHODS: Payments to the City of Summerville may be made by check, cashier's check, cash, money order, Master Card, Discover or Visa. A check issued to the City of Summerville that is returned to the city without being honored by the writer's bank will be have the associated City of Summerville utility services disconnected immediately. Having two checks returned within a six (6) month period will result in said utility account being marked as "No Checks" for a twelve (12) month period following the second occurrence. DISCONNECTION POLICY: Failure to receive a utility bill does not abolish or relieve your responsibility of paying for your City of Summerville utility service. It is the customer's responsibility to see their bill is paid on time. It is the customer's obligation to contact this office at Monday through Friday between the hours of 9 am and 5 pm if you do not receive your bill. Any balance 15 days past the original due date is subject to disconnection. THEFT OF UTILITY SERVICE: Theft of City of Summerville utility service is subject to prosecution based on Georgia law. CONSUMER RIGHTS TO CONTEST A DISPUTED BILL: Nothing herein shall relieve the customer of being current with said utility account and continuing to remit payment for utility service received while the accuracy of such bill is being investigated/appealed. If such bill is determined to be in error, no late fees, penalties, or interest shall accrue and same shall be refunded where applicable. A residential consumer located outside of the municipal utility's home county shall have the right; after all remedial measures with the utility have failed, to request in writing, or orally to be followed by a request in writing, that the Georgia Public Service Commission investigate the dispute either before or after service has been terminated. By affixing my signature herewith I attest that the information submitted herewith is accurate, I have read and understand my responsibility to pay for utility services received, and acknowledge receipt of a City of Summerville Gas Department Information brochure providing important safety and emergency contact information. Signature Date

4 USER AGREEMENT WATER DEPARTMENT Date: I,, request water service at the property located at, Summerville, GA I am the (check one) Tenant Owner The undersigned does hereby grant to the City of Summerville a perpetual right to enter upon the real estate at this address at any time that it may see fit, to construct, inspect, maintain and repair pipelines and/or facilities necessary for the metering of this service. Should the City of Summerville afford a water supply as requested, the undersigned hereby agrees to assume all responsibility arising from breakage or leakage of pipes, damage to the metering device, or theft or unlawful removal of same. The undersigned also releases the City of Summerville from any and all damages caused by water from any breakage or leakage of mains and/or service pipes. The undersigned understands that, at times, the pressure of the City of Summerville water system will fluctuate and the undersigned assumes all responsibility of any and all damage caused by said pressured fluctuation. The City of Summerville strongly encourages the undersigned to purchase and install an AWWA approved pressure regulating device and have said device tested as per manufacturer recommendations and replaced as needed. The undersigned agrees to pay for the water supplied at the rates in force or which may be established hereafter and that such supply shall be subject to the rules, regulations, and conditions which the City of Summerville have heretofore adopted, or which may be adopted hereafter, from time to time, for the preservation, regulation and protection of the water system of the City of Summerville. Residence Business Tenant Owner Address By

5 USER AGREEMENT GAS DEPART Date:, request gas service at the property located at, Summerville, GA I am the (check one) Tenant Owner The undersigned does hereby grant to the City of Summerville a perpetual right to enter upon the real estate at this address at any time that it may see fit, to construct, inspect, maintain and repair pipelines and/or facilities necessary for the metering of this service. Should the City of Summerville afford a gas supply as requested, the undersigned hereby agrees to assume all responsibility arising from breakage or leakage of pipes, damage to the metering device, or theft or unlawful removal of same. The undersigned also releases the City of Summerville from any and all damages caused by gas from any breakage or leakage of mains and/or service pipes. The undersigned agrees to pay for the gas supplied at the rates in force or which may be established hereafter and that such supply shall be subject to the rules, regulations, and conditions which the City of Summerville have heretofore adopted, or which may be adopted hereafter, from time to time, for the preservation, regulation and protection of the gas system of the City of Summerville. The undersigned agrees NOT to put service pipes under concrete walks, steps or other permanent structures that may have to be removed and/or demolished if a leak should occur. The undersigned agrees to provide adequate access and space around, in front of and/or behind the metering device to allow reading, maintenance repair and replacement of said device. Residence Business Tenant Owner Address By

APPLICATION FOR UTILITY SERVICES

307 RUE SCHOLASTIQUE LAFAYETTE, LOUISIANA 70507 Phone: (337) 896-8683 Fax: (337) 896-8625 APPLICATION FOR UTILITY SERVICES APPLICANT S INFORMATION Name: APPLICANT INFORMATION First: Last: or Company Name: