New Account - Request for Service

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ATTENTION NEW CUSTOMERS:
The first bill of every new account will reflect a $30.00 administration fee for turning on water service, obtaining a reading and accounting records. Accounts are billed monthly and due 20 days from the bill date. Bills not paid by the due date shown on the bill are considered late and assessed a late fee of $5.00 or 1.5% or whichever is greater. Payments "in the mail" do not constitute payment. When accounts are turned off for non-payment, a $50.00 charge will be reflected on your next bill.

NOTE: If an unpaid previous balance appears on the bill, the unpaid amount is NOT extended to the current month's due date.

NOTE: If a special trip is made to the customer's premises (special reads, re-reads, customer requested meter tests), a trip charge of $30.00 will be applied to the monthly billing.

NOTE: You may also download a PDF version of this document here: New Account Application.pdf. A PDF reader such as Foxit PDF Reader or Adobe Acrobat Reader is required to view or print this file.


(Note: Unless otherwise noted, we will use the bank information that was previously on your account. Please verify the banking information with a Customer Service Representative)
SECTION I (please type or print)

TELEPHONE NUMBERS
IDENTIFICATION

In accordance to Florida Statute 119.071(5), the City of Cocoa's collection of social security numbers is imperative for the performance of its lawful duties and responsibilities. Social security numbers collected by the City of Cocoa are considered confidential and may not be used by this agency for any purpose other than the purpose provided in this written statement. The City of Cocoa collects your social security number for the following purposes: classification of accounts; identification and verification; credit checks; drivers license check; drug/alcohol testing and physicals; background checks; tax reporting; and police statements and arrests. Social security numbers are also used as a unique numeric identifier and may be used for search purposes.

DEPOSITS: A deposit is required for all water and sewer customers of the City except as specified in the Utilities Handbook and will be on the first months bill. Interest on deposits is credited quarterly to the customers account. Upon termination of the account, any deposit held by the City will be applied against the final bill. Any remaining balance will be forwarded to the customer of record.
***Residential customers with one year of good payment history will be refunded their deposits.

COLLECTIONS (Ordinance 21-2004): The City shall be entitled to recover all costs, including but not limited to reasonable attorney's fees and/or collection service charges, incurred in collecting delinquent utility fees and charges.

LIEN FOR DELINQUENCY: As promulgated in detail in the City of Cocoa Code of Ordinances, all utility rates, fees and charges assessed shall be lien upon the property with which such rates, fees and charges are associated.

IMPORTANT INFORMATION: The City of Cocoa is not responsible or liable for loss or damage to any person or property whatsoever, resulting directly or indirectly from flooding beyond the water meter. It is the customer’s responsibility to make sure all water inside the dwelling is turned off to avoid flooding. If a Field Service Representative cannot turn the water on due to water running, the customer must contact Customer Service office to reschedule for a later time/date.


I hereby request and authorize the City of Cocoa Utilities to supply water and/or sewer services to the above described property, as well as all other services which may be attached to the property. I also agree to pay for said services at the rate established by the City of Cocoa and other Utilities which we bill and abide by the rules and regulations applicable to said service as outlined in the Utility Handbook.


CSR_______________________ Received By: ___ Mail ___ Fax ___ E-mail ___ In-Person

SECTION II

IF YOU ARE UNABLE TO COME INTO THE OFFICE TO SIGN AND COMPLETE THIS FORM, YOU MUST HAVE THIS FORM NOTARIZED AND SUBMITTED TO CUSTOMER SERVICE ALONG WITH A LEGIBLE COPY OF YOUR DRIVER'S LICENSE AND SOCIAL SECURITY CARD.

STATE OF ______________________________

COUNTY OF ______________________________

Subscribed and sworn to (or affirmed) before me / personally known to me this _____day of_________20___

By____________________________________________________who is/has/have

Produced _____________________________________________________
(Type of identification)


___________________________________________________________________ Notary Public.

____________________________________________________________________________
(Name of Notary typed, printed or stamped)


Application must be filled out in its entirety

 
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