RUSSELL RESIDENTIAL MUNICIPAL UTILITY APPLICATION

APPLICATION FOR: Municipal Electric Service

Service to Begin On: _____________________________ Circle: Owner Renter--Other side must be filled out

Address for Service: ______________________________________________________Apartment #:______________________

Name _______________________________________________________ Social Security # __________________________

Present Address _________________________________________________________________ Years there: ______________

*Birth Date: _______________________ Telephone # Days: _______________ Evenings: ________________________

*(Applications by persons under 18 years of age must be co-signed by a parent, guardian, or a responsible adult who will guaranty payment in event of non-payment by the applicant.)

*Mailing Address and P.O. Box # ____________________________________________________________________________

*Notice: Since some of the Town of Russell does not have rural mail delivery service, you must have and maintain mail service to which bills can be addressed in order to have municipal Utility Service. If you close your account and do not inform the Town of a new billing address, your service will be discontinued!

Personal References: Name, Address, Telephone #, of relative or close friend for reference:

Reference #1:____________________________________________________________________________________________

Credit References: Name, Address, Telephone # of two companies or individuals who have extended credit to you in the last two years: If applicant has no credit a Co-Signer must fill out a second application and be responsible for the bill.

Creditor #1: _____________________________________________________________________________________________

Creditor #2: _____________________________________________________________________________________________

Employment Reference: Name, Address, Telephone #, of current employer. If unemployed write unemployed and explain how the service will be paid.____________________________________________________________________________________

_______________________________________________________________________________________________________

I understand that payment for Service is due no later than the 15th day after I receive the bill for the Service. Failure to pay on a timely basis will result in Service being discontinued. In order to reinstate service I must pay all past due bills, and any costs incurred by the Town as a result of my failure to pay, including but not limited to the costs of disconnecting and reconnecting Service, collection costs, court costs, and reasonable attorney's fees. I agree to notify the Town if I move out so that service will be terminated. Otherwise I will be liable for any utility costs incurred as a result of my failure to notify the Town.

I CERTIFY THAT I HAVE READ THIS APPLICATION AND AGREE TO ABIDE BY THE TERMS STATED HEREIN. I FURTHER CERTIFY THAT ALL INFORMATION PROVIDED BY ME IN THIS APPLICATION IS TRUE, AND AGREE TO INFORM THE TOWN UTILITIES OF ANY CHANGES IN THAT INFORMATION.

_____________________________________DATE__________ _______________________________DATE_________

APPLICANT CO-APPLICANT

Electric Security Deposit $200.00 or average 3 months usage (Circle) Cash Check # _________________________________

TOWN OF RUSSELL

MUNICIPAL UTILITY APPLICATION

ADDENDUM FOR RENTED PROPERTY

Name of Landlord:

Landlord's Telephone #:

Landlord's Mailing Address:

Street Address of Property:

Identification of Apt. (i.e. Apt #, previous renter, location, drawing)

I certify that I am the legal owner of the above referenced Property, and that I have agreed to rent the Property to: ___________________________________. I agree to notify the Town of Russell Municipal Utility's Board within five business days should the Tenant vacate the premises, so that Municipal Utility Service can be shutoff. I agree that should I fail to so notify the Town, and should utility bills be generated after the tenant vacates, I will be responsible to pay for all utility services provided to the Property by the Town subsequent to the Tenant's departure. I have been informed that all unpaid utility bills for which I am responsible can be converted into property tax on the Property pursuant to Massachusetts General Laws Chapter 164, 58B through 58F, and will be collectable as real estate taxes.

___________________________________________

Signature: Owner of the Property Date