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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 fve business days of the termination effective date. A final bill will be mailed to the account holder with the words "FINAL BILL"

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

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

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

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

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

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

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

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

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

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

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

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Federal Tax ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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*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.

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

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

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

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

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

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

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

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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 }

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*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.

Secuirty 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 is received and you can pay the deposit online ($3.00 fee applies) through our Water and Sewer Payments.

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

Cash: You may pay in person at 102 Town Hall Dr, Leland, NC 28451

Your services will not be active until the deposit is received.

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 }

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

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

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Draft from Credit Card

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

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

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

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

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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 errone-ous 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 ntoice 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 }

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

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

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

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

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

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

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