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New Account - Request for Service

  1. 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 processed for non-payment, a Non-Payment Processing Fee will apply.

    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 will apply.

  2. Customer Type*

  3. Are you a returning customer and previously enrolled in the ACH Debit program and wish to continue in the program?
    *

  4. (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)

  5. Application Type*

  6. Application Status*

  7. Please ensure ownership or tenancy documents are in a single file for upload.

  8. Note: Requests submitted after 2:00 PM EST will not be received until the next business day and will be processed for completion for the following business day. Requests submitted after 2:00 PM EST on Friday will not be received until the following Monday (excluding holidays) and will be processed for completion for the following business day. Please call (321) 433-8400 to confirm receipt of information and Service Start Date.

  9. Service Address

  10. Mailing Address

  11. Will your mailing address be different than your service address?

  12. TELEPHONE NUMBERS

  13. IDENTIFICATION


  14. 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. Disclosure of your social security number is voluntary, and the City will not deny rights, benefits, or privileges as a result of a refusal to provide it.

  15. Important Disclosures

    A) 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 to reschedule for a later time/date.

  16. B) The first bill of every service activation will reflect a $30.00 Service Initiation Fee.

  17. C) Deposits shall be held in an interest-bearing account and, if applicable, will be credited to the account after twelve (12) months of satisfactory payment history or applied to the final statement, whichever comes first. Any final credit balances will be refunded once it is determined there are no other outstanding utility debts due the City.

  18. D) Payments made to prevent disconnection of service, or, to restore disconnected service; that are returned, will result in immediate interruption of service and additional fees/deposits (if applicable) will be applied to the account.

  19. E) Tampering and/or self-restoration of service will result in “involuntary termination”. If an account is terminated for non-payment and then self-restored/tampered with, the Applicant on Record (tenant/owner) will be immediately disconnected and the meter will be locked (fees apply). Furthermore, once an account is involuntarily terminated, the Applicant on Record will be required to reapply for service and provide updated documentation.

  20. F) Delinquent accounts that continue to go unpaid are reported to a collection agency. Per Ordinance 22-18, the City shall be entitled to recover all costs, including but not limited to, reasonable attorney’s fees and/or collection services charges, incurred in collecting delinquent utility fees and charges.

  21. G) As detailed in the City of Cocoa Code of Ordinances, a lien will be placed on the property if an account in the Owner’s name remains unpaid.

  22. I hereby authorize the City of Cocoa Utilities to supply water and/or sewer services to the property provided on this application, as well as any 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 will be billed and abide by the rules and regulations applicable to said service as outlined in the Utility Handbook.

  23. Application must be filled out in its entirety.

  24. By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.

  25. Please call (321) 433-8400 to confirm receipt of information and Service Start Date.

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