Transfer of Water / Wastewater Utility Service Form

Transfer of Water / Wastewater Utility Service Form

If you have any questions about this application, please call our office at 1-877-718-4396.

Applicant Information Note: Please provide at least one phone number.
Name:
Billing Address:
City, State & Zip	,
Home Phone:	(ex. 512-555-1234)
Work Phone:	(ex. 512-555-1234)
Cell Phone:	(ex. 512-555-1234)
Email Address:
Last 4 digits of SS#:


Name of additional person authorized to make changes to this account:


Where will you be transferring service FROM?
Street Address:
City, State & Zip:	,
Approx. Move Out Date:	, (please allow a 2 business day notice)


Where will you be transferring service TO?
Street Address:
City, State & Zip:	,
Approx. Move In Date:	, (please allow a 2 business day notice)


What services are requested? Note: Please check at least one service box
	water at an existing location
	wastewater at an existing location
	wastewater at an existing location with grinder pump
	water at a new location
	wastewater at a new location
	wastewater at a new location with grinder pump
	temporary service - fire hydrant meter
	extension of service to unserved area


Additional Information
Applicant is:
Customer Type:
Meter Size:
If OTHER, specify size:	(in inches)


Is this a landlord account? (check if YES)


Do you have any special service needs?

	pool
	fire sprinkler
	irrigation

Other:


Under the Texas Utilities Code, Section 182.01 through 182.005, persons 60 or older with a utility account will not receive a 10% penalty until the bill is past due by 25 days.

Are you or any person authorized on this account 60 or older? (check if YES - age verification will be required)

Section 182.052 of the Texas Utilities Code requires government-operated utilities to notify customers of their right to confidentiality. You are hereby informed that you have the right to request confidentiality of your address, telephone number, social security number and information relating to the volume or units of utility usage and the amounts billed to or collected from you for utility usage, as contained in our records. If a customer makes such a request of confidentiality, LCRA shall notify you of the request and keep the information described above confidential unless required or mandated by law. Please be aware that if you requested confidentiality in the past, you also have the right to cancel that request for confidentiality. To exercise your rights, please complete the information requested on this form.

Do you request confidentiality of the information listed above? (check if YES)

I acknowledge by submitting this agreement that upon accepting service I will be subject to the terms and conditions of retail water and/or wastewater service as contained in the Rate Schedule, as updated from time to time at the discretion of the LCRA Board of Directors. I further acknowledge and agree that the terms and conditions of retail water and/or wastewater service contained in the Rate Schedule shall constitute a contract between LCRA and me and may be enforced as such.

Do you agree to the terms and conditions outlined in the Rate Schedule? (check if YES)

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