Application for New Water/Sewer Service


Date of Birth:     

Date of Birth:    

Service Address:

Drivers License#:
Social Security#:

Applicants Employer:
Emp. Phone:

Co-app Employer:
Co-app Emp Phone:

Has applicant(s) had service with City of Benton before? YESNO
If yes, when:

Do you owe a previous bill with the city? YESNO
If yes, how much?

Is the property inside Benton city limits? YESNO

If outside city limits an ANNEXATION AGREEMENT (direct or 20 year) must be signed and approved before water service can be established.

Is this a mobile home? YESNO

Rent or own? RentOwn
If renting:
Property owners name:      
Property owners address:  
Property owners phone#: 

Date service requested:

I, , will be responsible for paying all water and sewer bills that are incurred at the address for which I have requested service. If they are not paid as required, I understand that my water service may be discontinued and that I will be responsible for attorney fees, and any and all extra costs to recover the payment.

For renters there is a $150 deposit that must be paid in our office to connect water services. A copy of your deed/lease must also be on file in our office. Please bring it with you when you pay your deposit. Check this box too confirm your obligation to comply.