The service fee($30 inside/$40 outside) is non-refundable
Rental/Lease Agreement or Proof of Ownership is required
Date _________________________________
Name _____________________________________________________________________________________
Service Address _____________________________________________________________________________
Mailing Address ___________________________________ City, State, Zip Code ________________________
Home Phone (_______) _______-_________ Work Phone (_______) _______-__________
Residential _______ or Commercial _______ (Check One) Owner _______ or Renter _______ (Check One)
Date of Birth _____/_____/_____ (mm/dd/yy) Social Security Number _______-______-________
Race W: _____ B: _____ H: _____ Other: _____
Driver License Number _________________________ State of Issue ________________________________
Adult Co-Habitant _________________________________ Number of people in the Household ____________
E-Mail Address _____________________________________________________________________________
Employer __________________________________________________________________________________
Employer Address ___________________________________________________________________________
Have you ever had Hartsville Utility service before? Yes:_____ No:_____
If so, enter last service address ________________________________________________________________
If renting or leasing provide the name and telephone number of the property owner and/or rental agent in the
area provided below.
Owner/Rental Agent name: _________________________________________
Owner/Agent telephone number (_______) ________-_____________
DO NOT WRITE BELOW THIS LINE - ADMINISTRATIVE USE ONLY
_______________________________________________________________________________________________________________________________________________________
Connection Date _______________________ Account # ________________________
If this property is a rental property outside of the corporate limits of the city of Hartsville, is there an
Annexation agreement on file?
____________
Copy of rental agreement on file? _____________
Copy of driver's license on file? _______________
Service Fee Paid: Inside $_____________ Outside $_____________ Turn Over
UTILITY SERVICE AGREEMENT
Fax completed form to: (843) 383-3040
Mail completed form to:
City of Hartsville, Attention: Finance
PO Drawer 2497, Hartsville, SC 29551
This agreement, when signed by the Consumer and by and authorized representative of the City of Hartsville, shall
become a contract under which the City of Hartsville agrees to furnish Utility Services to the individual Consumer, and
the Consumer agrees to receive and pay for said service in accordance with the Rate Schedule and the Service
Regulations of the City of Hartsville on file in the office of the City of Hartsville, and as the same may be modified from
time to time, which Rate Schedules and Service Regulations are hereby made a part of this contract as effectually as if
fully set forth herein.
The Consumer must maintain a safe passageway for meter access by the City of Hartsville. Additionally, the Consumer
has the responsibility to keep the meter free from obstructions and to restrain pets or by removing obstacles that the City
of Hartsville might encounter at that property. Failure of the Consumer to provide free access may result in the termination
of utility service until suitable access is provided. Bills may be rendered on the basis of estimated meter readings
whenever the City of Hartsville is unable to obtain a meter reading because of inaccessibility to the Consumer's premises,
or for other reasons. In any case, consumption shall be estimated based upon the best information available.
The Consumer shall not interfere with, or alter the City of Hartsville's meters, seals, or other property, or permit the same
to be done by other than the City of Hartsville's authorized agent or employee. Damage caused or permitted by the
Consumer to said property shall be paid for by the Consumer. When unauthorized use of utility services is discovered, the
City of Hartsville may discontinue service and the Consumer shall be required to pay for the estimated unauthorized
usage, the cost of investigation, reconnection, and any other loss resulting from the changing, tampering, or interfering
with the meter, before service is restored.
The City will make all reasonable efforts to provide continuous and uninterrupted utility service, but cannot be liable for
loss or damage (direct, consequential or otherwise) caused by an failure to supply electricity, water - sewer, or by an
interruption, if it is due to any cause beyond the reasonable control of the City. The City cannot be held accountable for
acts of God.
Unless otherwise provided, this agreement shall continue from month to month thereafter. The same may be terminated
by either party after expiration of any fixed period initially specified, upon one working day notice to the other. It is further
agreed that the City of Hartsville reserves the right to discontinue services if the Consumer breaches this service
agreement. If the service is disconnected for cause, the Consumer agrees to pay all outstanding bills and an applicable
reconnection fee for service to be restored. The Consumer understands that the information furnished on this application
will be verified and if determined inaccurate, will result in the termination of service without prior notice. The Consumer
acknowledges that the City of Hartsville shall have the right to share the Consumer’s customer account information and
other information with other utility providers.
The applicant understands that the City must take action and expend funds to comply with this request for service. By
signing the application, the applicant signifies that he or she has the authority to request utility service at the location
identified above.
The Consumer who signs for service agrees to be responsible for receipt and payment of bills for these services. Failure
to receive a monthly bill does not relieve Consumer of payment responsibility. It is further understood that should the non-
refundable service fee be determined insufficient, the Consumer will make and additional non-refundable service fee upon
request from the City of Hartsville not to exceed the two highest months utility bills.
I attest that the information given on this contract is true and accurate to the best of my knowledge.
ADDENDUM
By signing this application for Water, Storm Water, Sanitation, Sewer and Yard Debris with the
City of Hartsville; the applicant agrees to pay all costs of collection of the applicant’s unpaid
bills. The City of Hartsville has the right pursuant to the South Carolina Setoff Debt Collection
Act to collect any sum due and owed by the applicant through offset of the applicant’s state
income tax refund.
If The City of Hartsville chooses to pursue debts owed by the applicant through the Setoff Debt
Collection Act, the applicant agrees to pay all fees and costs incurred through the setoff
process, including fees charged by the Department of Revenue, the South Carolina
Association of Counties, the Municipal Association of South Carolina, and/or The City of
Hartsville. If The City of Hartsville chooses to pursue debts in a manner other than setoff, the
applicant agrees to pay the costs and fees associated with the selected manner as well.
By _____________________________________ X ________________________________________
Customer Service Representative Applicant’s Signature
Date____________________________________ Date______________________________________