Are you a: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please select one of the following: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please select one of the following options: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you a {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please select one of the following {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you are the tenant, please provide rental agreement and list the name of the owner/property management company and their contact information.

Residential account holders may complete this form after one (1) year of uninterrupted service or upon the disconnection of service, whichever is earlier, to receive the utility deposit refund.

You must have a good payment history (i.e. no returned checks or disconnects for non-payment, and with only two late penalties) within the past twelve (12) months.

Residential account holders may complete this form to arrange disconnection of services. Final readings will be taken on metered services within five business days of the termination effective date. A final bill will be mailed to the account holder with the words "FINAL BILL"

Form of refund? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Landlord's Name and Contact Info {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Service Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have a closing disclosure or settlement statement? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please upload closing disclosure or settlement statement. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

If you do not have a closing disclosure or settlement statement, we suggest you wait until the house has gone to closing and you have the appropriate paperwork in order to complete this application.

File Upload {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Effective Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Effective Disconnect Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Social Security # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email for Invoice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Business Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Business Name or First/ Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Service Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email for invoice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Co - Applicant Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Social Security # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Co - Applicant Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Co - Applicant Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Business Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Service Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Subdivision {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Forwarding Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

x {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

When submitting the residential water and sewer application, please also submit a copy of the building plans.

Upload File {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Type of Facility {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Work Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Type of Dwelling {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

*In completing this application and in accordance with 15A NCAC 02T .0114, each bedroom or any other room or addition that can reasonably be expected to function as a bedroom shall be considered a bedroom.

Commercial Water & Installation Fee {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Commercial Irrigation & Installation Fee {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Water System Development Fees

Commercial Based on Occupancy

Sewer System Development Fees

Commercial Based on Occupancy

Commercial Irrigation System Development Fees {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Water System Development Fees {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sewer System Development Fees {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Residential Water & Installation Fee** {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Will the irrigation be transferred to an HOA upon sale of the property? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

**The Town of Leland will install the meter and meter box. The applicant must install all backflow prevention devices - dual check and backflow preventer in accordance with Town standards.

Once application has been reviewed, you will be invoiced with total fees due.

**DO NOT REMIT PAYMENT AT THIS TIME!**

CERTIFICATION: I certify that I am authorized to make this application and the information provided is correct to the best of my knowledge. I understand this account will be my responsibility until a new applicant makes an application with the Town of Leland.

Paperless Bill (Go Green) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

*There is an additional utility deposit required from applicants that choose not to provide a social security number, this could be used as a personal identifier for internal records, fraud prevention and collection purposes through North Carolina local government debt setoff clearing house. Service can be refused for prior utility delinquencies. Code of Ordinance can be found on our website at www.townofleland.com (these are subject to change at any time, I understand that I will be held accountable to these new changes.) I hereby certify that the above information is true to the best of my knowledge.

Security Deposit: $200.00 (It is required that everyone pays a deposit regardless of credit history)

Debit/Credit Card: You will be provided with the account number through email after the application has been processed.

Check: Please make checks payable to "Town of Leland". Checks can be mailed to 102 Town Hall Dr, Leland, NC 28451.

Please Select A Meter {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Type of Meter {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Town Meter Pricing

3/4" Meter

Deposit $200.00

Base Fee $5.00 per Day

All Usage (0-6,000) $4.00 per 1,000

All Gallons (over 6,000) $5.27 per 1,000

Hookup Fee $50.00

Town Meter Pricing

3" Meter

Deposit $1,000.00

Base Fee $15.00 per Day

All Usage (0-6,000) $6.04 per 1,000

All Gallons (over 6,001) $7.06 per 1,000

Hookup Fee $50.00

Personal Meter Pricing

3/4" Meter

Deposit $200.00

Base Fee $5.00 per Day

All Usage (0-6,000) $4.00 per 1,000

All Gallons (over 6,000) $5.27 per 1,000

Hookup Fee $50.00

Personal Meter Pricing

3" Meter

Deposit $200.00

Base Fee $15.00 per Day

All Usage (0-6,000) $6.04 per 1,000

All Gallons (over 6,001) $7.06 per 1,000

Hookup Fee $50.00

Comments: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

I authorize the Town of Leland to have my Utility Payment drafted directly from my bank account or other financial institution. I understand that my account will be drafted on the due date indicated on each statement. I also understand that if the draft is rejected because of insufficient funds or other reason, I may be subject to additional fees.

Draft from Checking Account

Financial Institution Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bank Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bank Transit/Routing Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Draft from Credit Card

Credit Card Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expiration Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name on Credit Card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Billing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I authorize that this auhorization will be in effect until I notifty Town of Leland in writing that I no longer desire this service, allowing it is reasonable time to act on my notification. I also understand that if corrections in the debit amount are necessary it may involve an adjustment (credit or debit) to my account.

I have the right to stop payment of a debit entry by notifying my financial institution before the account is charged. If an erroneous debit entry is charged against my account, I have the right to have the amount of the entry credited to my account by my financial institution. I agree to give my financial institution a written notice identifying the entry, stating that it is in error, and requesting credit back to my account. I will provide this writtten notice within 15 calendar days following the date on which I was sent a statement of my account or a written notice of such entry, or 45 days after posting, whichever occurs first.

Add/Change Name On Bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Remove Name On Bill {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Change Billing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email Address Change {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone Number Change {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Requested by {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship to account {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}