City of Mosinee

1 city of Mosinee water & sewer utility APPLICATION FOR SERVICE Property Information: Property Address: Today's Date: Date to Start Service: Is this a rental? Yes No If this is a rental, please provide Landlord information on the lines below: Landlord Name: Landlord Phone Number: Mailing Address for Landlord: city State Zip Name(s) of All Customers responsible for Payment of water and sewer Bill: Mailing Address If Different from Property Address: city State Zip Telephone Number(s) Email Address: Billing and Payment Information: utility bills are mailed around the 10th day of each month and payments are due 20 days from the billing date. Payments are accepted at city Hall (in person and by mail), in the drop box outside city Hall, or via Online payment methods located in the Online Services Section of our city website. The Mosinee water and sewer utility offers direct payment of your bill each month from your Savings or Checking Account (see Automatic Payment Section Below) To avoid disconnection of service, payment arrangements can be made.

2 Please contact the Mosinee water and sewer utility office for additional information. Yes I would like to enroll in paperless billing Please email my monthly bill to the following email address: _____@ _____. _____ I understand that by electing to receive my water / sewer bills via email that I will not receive a paper bill. water & sewer utility APPLICATION FOR SERVICE Automatic Payment Authorization By completing this section, I (We) authorize the city of Mosinee water and sewer utility to deduct funds from the account listed below: Financial Institution Name: Financial Institution Address: Payment Type Checking Savings Bank Routing No: Bank Account No: Funds will be removed from your account on the due date of the billing for the amount due. Sprinkler Credit The Mosinee water and sewer utility offers a Sprinkler Credit Program. This program is currently available from May Thru September.

3 When you sign up for the program, the city will compare your water and sewer usage during the summer and winter months. An average sewer amount based upon your winter usage is then used during the summer months to calculate your bill. You will be charged the full amount of any water used. The Mosinee water and sewer utility can provide you with a savings worksheet if you need more information. The sprinkler credit has a one time setup charge of $50. Yes I am interested in the Sprinkler credit program. Please charge my account the one time $50 fee. No I am not interested in this program at this time. Consent to Release water / sewer utility Information PURSUANT to and in accordance with Wis. Stat. Sec. , the city of Mosinee water and sewer utility is hereby authorized to release my/our municipal utility customer account usage and status information to the landlord of this property (if rental).

4 Signature of Applicant: Date: Signature of Applicant: Date: Terms and Conditions of Service The applicants are jointly and severally liable for utility charges at the service address. The Mosinee water and sewer utility agrees to furnish, and the customer agrees to take and pay for, said service in accordance with the provisions and rates of the Mosinee water and sewer utility , and subject to all the applicable rules of the Public Service Commission. Signature of Applicant: Date: Signature of Applicant: Date: Office Use Account No: Meter Reading on Requested Date: Send Final Bill to: Notes: Return application to: city Clerk, 225 Main Street, Mosinee , WI 54455