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2. 
4. Section 1: Account Holder Information
   Please provide full contact information for the individual that the account is listed under.
6. Name*
8. Mailing Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Alternate Phone Number
17. E-mail Address*
18. Account #*
20. Forwarding Address Information:
    Please provide a forwarding address for final billing and account deposit return.
22. Forwarding Address*
24. City*
25. State*
26. Zip Code*
30. Section 2: Service Location Information
    Provide full information for the location in which the account is associated with.
32. Date for Service to Cease*
    Date for Service to Cease
34. Service Address*
36. City*
37. State*
38. Zip Code*
40. Is this property a rental?*

    1. Yes
    2. No

    If yes, please fill out the information below. If no, proceed to Section 3.
42. Rental Property Information
    If the service property is leased, please provide the landlord’s contact information below. Please be aware if you lease, your landlord will be notified if you are delinquent on your account per Ordinance #864. If you are the landlord, and you require your tenant to be responsible for payment, a copy of the Village of Elwood’s Landlord/Tenant policy is available for your review upon request.
44. Indicate Your Status

    1. Tennant
    2. Landlord
45. Indicate Responsible Party for Utility Bill

    1. Tennant
    2. Landlord
47. Landlord's Name
48. Landlord's Phone Number
50. Landlord's Address
52. City
53. State
54. Zip Code
58. Section 3: New Owner & Seller's Attorney Information
    Provide information where you able to assist the Village in setting up the next account.
60. Seller's Attorney Name
    *If applicable
61. Phone Number
63. Do you know the new owner/renter's contact information?*

    1. Yes
    2. No

    If yes, please fill out the information below. If no, proceed to Section 4.
65. New Resident's Name
66. Phone Number
70. Section 4: Terms & Conditions of Terminating Your Utility Account
    Listed below you will find the terms and conditions of the Village of Elwood in regards to the water, sewer and garbage utility billing collection procedures. Please read and understand the policies.
72. Prorated Usage: Billing Policy*

    1. I understand the below statement.

    Anyone moving in our out will have their first or final water/sewer/garbage bill prorated based on readings and number of garbage days on the property.
74. Prorated Usage: Water & Sewer*

    1. I understand the below statement.

    If the water/sewer use is under the minimum usage limit, the use is prorated by the 1,000 gallon charge. If usage is over the minimum 2,000 gallons, the customary fees are charged with the exception of garbage.
76. Prorated Usage: Garbage Service*

    1. I understand the below statement.

    Garbage is prorated by how many pick-up days the resident was legally living at the service address, and charged for only those days of usage.
78. Information

    Please submit any additional information, attachments by fax to (815) 423-6861, by email to utility@villageofelwood.com or by mail to Village of Elwood, 401 East Mississippi Avenue, Elwood, IL 60421. Any questions call 815-423-5011.

80. Signature and Authorization
    By signing below, I am confirming that all information provided is valid to the best of my knowledge and I agree to all terms and conditions as outlined above. I also understand that at the time I vacate the above listed property, I will notify the Village of Elwood thirty (30) days prior to my vacancy and provide a utility termination form for final billing. I understand that my deposit of $150.00 will be refunded within thirty (30) business days of my termination date and any outstanding balances on my account will be deducted from said deposit.
82. Electronic Signature*
    By providing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.
83. Date*
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit Submit and Print

* indicates a required field