Date: ______________ 20____

Name: ___________________________________________ Account #________________

Address: _____________________________________________

City:______________State:_____ Zip:_____________

Home Phone: ________________

Work Phone and Contact Name: _________________________________________

Service Address: _____________________________________________________

I hereby authorize Bartonville Water Supply Corporation (BWSC) to send the bills on my account to the person and address below:

Name: _________________________________________

Address: _____________________________________________

City:______________State:_______ Zip:___________________

Home Phone: ________________

Work Phone and Contact Name: _________________________________________

EFFECTIVE DATE: ___________________ 20_____

 I understand that Bartonville Water Supply Corporation will bill the renter/lessee named above for water service as a third party, but I, as the Member, am fully responsible for any and all unpaid bills left by the renter/lessee. I shall take responsibility for any necessary deposits from the renter/lessee to ensure payment of a past due bill. Should this account become delinquent, water service will be subject to termination under the policies of the Corporation, and shall not be reinstated until all debt to the Corporation has been paid. The Corporation will notify me, the Member, of the renter/lessee’s past due account status subject to disconnection of service.

I understand that I must sign a new Billing Authorization each time I want the billing changed. If the person authorized to receive the billing notifies the Corporation to take a final reading, the billing will automatically revert back to me.

Signature:

_________________________________________________________

Date of Signature:

____________________________

Bartonville Water Supply Corporation Representitive:

_________________________________________________________