Third Party Billing Agreement Third Party Billing Agreement Date of Application* MM slash DD slash YYYY Effective Date* MM slash DD slash YYYY Account Number* Service Address* I request the billing for water service as identified above, be mailed to: Third Party InformationThird Party Name* Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (if different than Service Address)Phone 1*Phone 2Owner InformationProperty Owner Name* Property Owner's Account Number Home PhoneWork PhoneMailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code By State Law, Citrus Heights Water District (CHWD) looks to the land that received the service for payment. For this reason, CHWD requires the Owner to keep the account in their name, but as a courtesy, CHWD will bill the Third Party listed above. As a result, CHWD requires a deposit, in the amount of $224.00, on all locations that are occupied/vacant and are billed to the Third Party as directed on the Third Party Agreement. It is the responsibility of the Third Party to pay the deposit. The deposit will be retained for the duration of this agreement and any subsequent Agreements until transfer of ownership. At that time, the Third Party must make a written request for the refund of the Deposit balance. Any outstanding balance on the account must be paid in full prior to the refund. Interest will be credited to the deposit account on a quarterly basis. The Third Party is responsible for any outstanding balance including but not limited to any additional fees that have been incurred, including late-payment penalties, Disconnect/Reconnect service charge as set forth in the District’s current Water Rates and Miscellaneous Charges and Fees. The District also has the right to place a Certificate of Lien on the parcel or pursue other collection opportunities I have read and consent to the terms of this agreement, including payment of the required deposit to complete this process. Responsible Party Signature Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ SIGN UP FOR ONLINE BILL PAY TODAY! GO PAPERLESS NOW
