Form must be filled out completely.

1

Date:

 *

Date:

2

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

 *

Physical Address

3

I understand I will be receiving and paying the City of Kalama utility bills for the above property.  I understand if I am delinquent, a copy of the late notice will be sent to my landlord.  If I am unable to pay the balance in full when it becomes due, I am to contact the landlord with proposed payment arrangements.  If the landlord agrees to the terms, the landlord will contact the City of Kalama with the proposed arrangements and indicate approval.

 *

Name of Tenant(s)

4

Tenant Mailing Address (if different from physical address)

Tenant Mailing Address (if different from physical address)

5

Date of Occupancy - Lease

 *

Date of Occupancy - Lease

6

Tenant Phone Number

Tenant Phone Number ext.

7

Tenant Cell Phone Number

Tenant Cell Phone Number ext.

8

Tenant Email

Tenant Email

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

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

Page 1 / 1