Form must be filled out completely.

1

Date:

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Date:

2

I verify I am the owner of the property located in Kalama, Washington at:

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Address

3

As owner of this property, I hereby request that the following renter be allowed to receive and pay the utility billing of the City of Kalama.  I understand I will be sent a copy of any late notices mailed to the tenant.

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Name of Tenant(s)

4

Date of Tenant Lease - Occupancy

 *

Date of Tenant Lease - Occupancy

5

Tenant's Mailing Address

Tenant's Mailing Address

NOTE:  If a complete mailing address is not provided for the tenant, the utility bill will be sent to the property owner.

6

Tenant Phone Number

Tenant Phone Number ext.

7

Tenant Cell Phone Number

ext.Tenant Cell Phone Number

8

Tenant Email

Tenant Email

This form acknowledges that the property owner is aware that even though the tenant is receiving the bill, should the tenant default, the property owner, by State law, [RCW 35.21.290 (water), 35.21.150 (garbage), 35.67.200 (sewer)] is still responsible for the payment of the water, sewer, and garbage bills.

I understand that as owner I am responsible to notify the City of any changes in tenants and that I am responsible for any bills that occur prior to the DATE OF NOTIFICATION of new tenants and during vacancies.

9

I acknowledge I am still the responsible party for payment of the utility bills should the renter not make the scheduled payments.  If the renter is not able to make the scheduled payment, please take the following actions regarding the water account:

I acknowledge I am still the responsible party for payment of the utility bills should the renter not make the scheduled payments. If the renter is not able to make the scheduled payment, please take the following actions regarding the water account:

Allow partial payments/payment arrangements with tenant to avoid shut off. The City will notify you when a new bill is issued and the previous bill remains unpaid.

Do not allow partial payments/payment arrangements and require balance to be paid in full to turn water back on should a termination of service for nonpayment occur.

10

If partial payments are allowed, do not allow the outstanding balance past due to exceed:

If partial payments are allowed, do not allow the outstanding balance past due to exceed:

11

Property Owner's Name

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Property Owner's Name

12

Property Owner's Address

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Property Owner's Address

13

Property Owner's Phone No.

 *

Property Owner's Phone No. ext.

14

Property Owner's Cell Phone No.

Property Owner's Cell Phone No. ext.

15

Property Owner's Email

Property Owner's Email

By submitting this form, you acknowledge that you have read and understood the authorization and agree to all its terms and conditions. You furthermore acknowledge that you have the authority to give this authorization.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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