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2. Applicable Addresses

   I authorize the City of Ashland to bill me for utility services used in my rental units between tenants at the following service locations: 

4. Address 1
5. Account # 1 (for office use only)
7. Address 2
8. Account # 2
10. Address 3
11. Account # 3
13. Address 4
14. Account # 4
16. Address 5
17. Account # 5
19. Authorization

    The utility service will automatically be left on and billed to me when the tenant’s account is closed. * 

    I understand it is my responsibility to notify the City of Ashland to terminate the interim billing when the units are rented. If proper notification is not received, I understand that I am responsible for the billing up to such time. If the authorization for billing is not signed and returned we will continue as normal to disconnect the service between tenants. When returned, this authorization will be effective two working days after receipt by the City of Ashland Utility Division and will remain in effect until canceled in writing by you or by the City. 

    *If an above listed account (when in your name) is disconnected by the City of Ashland for non-payment, the terms of this agreement will not apply. If disconnected while in the tenants name for non-payment, the account will not automatically be switched into your name. Service will only be restored after all fees are paid and/or we have received information for connection of services.

21. Billing Name*
23. Mailing Address*
25. Phone Number*
26. Email Address*
28. Title
29. Drivers License*
31. Signature (Type Name)*
32. Date*
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field