FOR LANDLORD USE ONLY Application for Automatic Reinstatement of Responsibility for Utility Billing Charges

FOR LANDLORD USE ONLY: Please contact the Treasury Office at (269) 329-4455 to set up water/sewer services in your name. Upon receipt of this signed application, the City of Portage can automatically reinstate property owners or property managers to utility billing accounts when a tenant leaves. The city interrupts services when no billing information is received at the time of a final meter reading. This automatic reinstatement will avoid any such service interruptions (other than when water is turned off for non-payment). This is a free service that will be effective upon receipt of this form by the Treasury Office.

Phone Number:

Email:

Driver License Number & State:

Date of Birth (00/00/0000 Month/Day/Year):

Select the type of third party (Select one type only):

Property Owner

Property Manager

Other (Please identify)

Please Identify "Other":

By signing this agreement, you initiate Automatic Reinstatement of Responsibility for Utility Billing Charges and indicate that you understand that you must cancel this authorization upon sale of the property.

Electronic Signature Agreement*

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Treasury Staff Only

Owner Customer Number

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*FOR LANDLORD USE ONLY* Application for Automatic Reinstatement of Responsibility for Utility Billing Charges

FOR LANDLORD USE ONLY Application for Automatic Reinstatement of Responsibility for Utility Billing Charges