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SCMU Application for Additional Water Allotment for Large Single-Family Households

SANTA CRUZ MUNICIPAL UTILITIES (SCMU)

Application for Additional Water Allotment

for Large Single Family Households

1. APPLICANT INFORMATION

Customer Name:*
as it appears on your utility bill
Identification:*
Identification Number:*

Primary Phone Number:*
(###) ###-####
Alternate Phone Number:
(###) ###-####
E-mail Address:*

2. ACCOUNT INFORMATION

Service Address:*
as it appears on your utility bill
SCMU Account Number:*
e.g. 010-10031-001

3. OCCUPANCY INFORMATION

Total number of persons who permanently reside at the above service address:*
(A permanent resident is someone who resides at the service location for at least 21 days within each monthly service period.)

4. DECLARATION

I, the above-named customer, declare, under penalty of perjury, that I am the account holder for the above account, and that the above information is true and correct. I understand that I am responsible for notifying the City of Santa Cruz Water Department within 10 days if the number of persons who permanently reside at the residence changes. I understand that false information will result in Excess Use Penalties for any water used over the standard allotment, and could result in discontinuation of water service and/or full prosecution as allowed under the laws of the State of California.
Please type the following sentence in the field provided: *
I have read, understand, and agree to the above declaration.
Signature:
Please type name here
Date:*
mm/dd/yyyy