Issue Tracking

Issue Tracking

New Service Application

*Start Service Date :
*Customer Type :
*Services Requested :	WaterIrrigation
*Customer Name(s) :
*Phone :
Cell Phone :
Email :
*Do you have, or have you ever had, service with us before?

If yes, please list all addresses which you currently have, or previously had, service:

Service Address
*Address :
*Zip :
Mailing Address (if different than service address)
Address :
Suite/Unit :
City :
State :
Zip :
If you are renting the home
Homeowner's Name :
Address :
Suite/Unit :
City :
State :
Zip :
Homeowner's Phone :
Agreement & Verification By digitally signing below I agree that I am responsible for utility bills for service dates after the above-listed request date for service to start. I understand that if I am the owner of the property I will be responsible for paying $110.00 deposit for water and sewer, and an additional $60.00 deposit if my home has access to an optional irrigation meter. If I am the renter of the property I understand that I am required to pay a deposit of $190.00 for water and sewer, and an addition $60.00 deposit if my home has access to an optional irrigation meter with either check or cash at the time I apply for service. This is a security deposit which will be returned after 23 months of good payment history or with the final bill if the account is closed before then. I also understand that I may also be billed a one-time service fee of $25.00 which will be billed to me on my first utility bill. I give the City of Palm Coast permission to establish utility service in my name. (If you are an owner, please present a copy of your HUD Settlement Statement or deed. If you are a renter, please present a signed copy of your lease. Picture ID for all adults on the deed or lease must be presented to our office at 2 Utility Drive.)
*Driver's License # :
*Last 4 Digits of SS# :
*Occupation :
*Type Your Name :

Your Contact Information

Completing the fields below will allow us to follow up with you regarding this issue, but is not mandatory.

First Name :
Last Name :
Phone :
Email :

About Our City \| For Residents \| For Businesses \| Local Government	City of Palm Coast 160 Cypress Point Parkway Suite B-106 Palm Coast, FL 32164 Tel: (386) 986-3700
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