Customer Service Division
Municipal Services Building
1401 John F. Kennedy Blvd
Philadelphia, PA 19102
Phone: 215-686-6880
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Application Date
Residential Tenant Applicant Information
Applicant #1
Owner Information*
Last Name First Name M I
Photo ID Type and Number
Telephone # Cell phone/e-mail address
Applicant #2
Last Name First Name MI
Telephone
Address:
House # Street Address
Last Name Fir
st Name M I
Photo ID Type and Number
Telephone # Cell phone/e-mail address
Yes No
Are you an agent for the owner/previous or current tenant customer? □□
Are you currently receiving water service at another address? □□
Do you owe any balances on water service at another property? □□
Would you like an application for our Customer Assistance Programs
including TAP and Senior Citizen Discount?
□□
Application language preference:
I/We occupy the referenced service address as (a) residential tenant(s)
and agree to pay for water service supplied in my (our) name(s).
I/We understand that submission of false or incomplete information may result
in the rejection of this application or the revocation of Customer status. I/We
understand that upon approval of this application, I/We are entitled to the same
rights and subject to the same obligations as any other Authorized User
of the utility service , including termination of service for non-payment.
City State Zip Code
*The owner's address may be the property address
if t
he owner resides at the property.
Agent Information (if other than owner)
Telephone
Last Name First Name MI
House # Street Address
City State
Zip Code
For staff use only
Verified: record ____________
Unable to verify by:
rep._______________ date ____________
Signature (Applicant #1) Date
Signature (Applicant #2) Date
For staff use only, do not write in this section
□ ID □ Lease Lease Date__________ □ Rent Book/Receipts □ Current PGW bill
□ Cancelled Checks □ Current PECO bill □ Other _____________
□ Money Order Receipts Verified by
□ Meter reading_____________ Rep______________ Date_______________
Meter read date______________
Application Status
□
APPROVED
□
Issued Rights Information
The current bill will be prorated, and billing in your name will be effective _________using the meter reading you submitted
□
REJECTED
□
Unable to establish tenant status
□
Insufficient Personal Identification
□
No valid housing license
□
Owner Information needed (as requested above)
□
Account noted "no tenant applicants" by owner
□
No active water account at lease inception
□
Documents needed:
□
Other:____________________________
__________________________________________ ____________________________________
Water Revenue Bureau Representative Date
Residential Tenant Application
Revised 1/11/18
For a list of required documents, please follow this link to
Tenant Water Customers: https://www.phila.gov/documents/tenant-water-customer/
click to sign
signature
click to edit
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click to sign
signature
click to edit
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