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Residential Utility Service Contract

  1. This section for office use only

    New Account _____      Transfer Fee _____      Modification_____ 

    Account#: _______-____________-_______ 

    Bad Debt search completed: _____      Application Fee added: _____      

    Deposit Amount: $_______

    Water _____      Sanitation _____      Sewer _____      EMS _____      

    Extra Trash Poly Cart _____      Extra Recycling Poly Cart _____      

    Users Fee _____      Water Fee _____      Need Inspection  _____      Service Order Sent  _____      

    Clerk Initials______



  2. Have you previously had utility services with the City of Chickasha? *
  3. This could be a spouse, child, trusted friend or family member, etc. who can access your account information.
  4. This could be a spouse, child, trusted friend or family member, etc. who can make changes to your account.
  5. Service Contract - Residential
  6. Agreement
    The undersigned, hereafter called the "Applicant", hereby applied to the following service, Water from the City of Chickasha Municipal Authority, hereinafter called the "Authority", with the execution of this application, the Applicant agrees to the terms of this agreements.
  7. 1.*

    The Applicant will pay forthwith to this Authority the sum of ($55 for a homeowner, $80 for a renter) as a deposit for the Utility services. Deposit will be retained by the Authority until service is disconnected. Upon the issuance of the final bill, the deposit will be applied to the outstanding charges and the balance, if any remains it will be mailed to the forwarding address on file.

  8. 2.*
    The acceptance of this application by the Authority shall constitute an agreement between the Applicant and the Authority, and the contract for Utility Services shall continue in force form the date of services made available to the Applicant, by the Authority, and thereafter until cancelled by either party.
  9. 3.*
    The Applicant will purchase from and pay the Authority for: Water Service and Refuse Collection charge to be used on the premises described below. The Applicant will pay said bill for services by the due date of each month or pay such penalties and fees as may be assessed by the Authority.
  10. 4. *

    The Applicant will comply with and be bound by the provisions of the regulations of the Authority. If any delinquent account is turned to collections or an attorney, or if suit is filed, all costs and attorney fees associated therewith, fees, costs, and expenses, shall be added to the delinquent account.

  11. 5. *

    Applicant hereby agrees to furnish the information as required by the Authority. Any information found to be false or not supplied, hereby beeches the contract and the above said services can be terminated at the option of the City of Chickasha Municipal Authority.

  12. Upload one of the following documents: a copy of your lease agreement (renters) or proof of ownership (homeowners).

  13. Upload a copy of your valid, government-issued ID

  14. Leave This Blank:

  15. This field is not part of the form submission.