Utility Service Application :: City of Auburn Kansas

Date service to start

Americas/Chicago

Service Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Do you own or rent property? Required

Own

Rent

Primary Applicant

Primary Applicant Required

Valid Drivers License or ID Number Required

Social Security Number Required

I will call to provide my SSN over the phone.

Date of Birth Required

Americas/Chicago

Phone Number Required

Email Required

Mailing Address (if different from Service Address)

Address 1

Address 2

City

Country

State/Province

Postal Code

Employer

Employer Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Landlord Information

Only need to fill out if you are renting the property requesting service.

Landlord Name

Landlord Phone Number

Landlord Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Co-Tenant Information Required

Persons listed as co-tenants will be responsible for the utility service in the event of default by the primary applicant.

Secondary Applicant

Valid Drivers License or ID Number

Co-Tenant Social Security Number

I will call to provide my SSN over the phone.

Social Security Number is required. Once your application has been submitted, please call us with your Social Security Number.

Date of Birth

Americas/Chicago

Phone Number

Employer

Employer Address

Address 1

Address 2

City

Country

State/Province

Postal Code

Applicant(s) understand that the use of said utility services will be governed by the ordinance of the City of Auburn, Kansas, that the present rates may change from time to time by action of the Governing Body of the City, and that the City does not warrant and ensure the uninterrupted service of any utility. Applicant agrees to abide by all laws and ordinances concerning the use and prompt payment for such utility service.

The Privacy Act regulates the use of Social Security Numbers by government agencies. The City of Auburn requires the disclosure of Social Security Numbers upon completing a service application. The SSN may be used to collect delinquent account balances through the State of Kansas Setoff Program or contracted collection agency. No other use or distribution of SSN will be allowed. Failure to disclose required SSN will result in a denial of utility services.

Signature

Primary Tenant's Name (Signature)

Primary Tenant's Email (Signature)

Secondary Tenant's Name (Signature) (If applicable)

Today's Date Required

Americas/Chicago

File Upload

Include a copy of current DL or ID.

File Upload

Letter of Credit from most recent utility service (gas, electric, water) to decide if a utility deposit is needed.