City of LaFayette
LaFayette, Georgia
Application for utilities for residence
You must show proper identification, rent receipt or owner’s papers.
Full name _____________________ Spouse’s name ____________________
Social Security number ___________ Spouse’s Social Security number _________
Utility address __________________________ Check one: Rent ___ Own ___
Mailing address ______________________________________________________
Utilities requested: Electricity ___ Water ___ Natural gas ___ Sanitation ___
Previous/current address: ______________________________________________
Have you or your spouse ever had utilities with the city before? _______
If yes, when and in what name? ________________________________________
List other people over 18 years living in the residence ________________________
Name of last residents at this address ____________________________________
Where are you employed? ________________ Previous employer __________
Landlord’s name _____________ Address ___________ Phone ________
_______________________________________________________________________
Please, read carefully.
I understand that my utility bill will be due on the _____ of each month and should be paid within 15 days and a late charge of 10 percent will be added after the due date. Service will be disconnected if not paid within 20 days from the date the bill is mailed. A connection fee will be charged before utilities will be turned back on. Utilities will be disconnected upon finding that the structure served has been or is being used for the manufacturing of any controlled substance, as provided by Sec. 21-27 et seq. Code of Ordinance.
Notice: A false statement in this application could result in disconnection of power!
I have received a copy of the underground gas piping maintenance form.
Date _______________ Customer’s signature __________________________
_______________________________________________________________________
Deposit number _______ Date ________ Clerk's signature _______________
Bad debt shown _____ Amount due ______ Amount paid __________
Remarks ______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Return to Administration.