Rapid Valley Sanitary District - Water Service

Application for Service

Residential or Commercial: select one *

Residential (a single-family unit or dwelling)

Commercial (applies to, but is not limited to motels, hotels, rest homes, fraternal organizations, laundries, service stations, bottling works, hospitals, restaurants and wholesale, retail, business establishments, apartment buildings, multiplexes or multiple entities metered by one bulk meter.)

Service Address

Address *

Street *

City *

State *

Zip Code *

Date to start service *

Owner or Renter *

Owner

Renter

RENTERS: We require verification from your landlord or property manager. Please have them contact us at 605-393-1050 to authorize the account, or provide a copy of the lease agreement below.

Upload image of Lease of agreement (jpg or pdf )

First Name *

Last Name *

Phone *

Email Address *

Date of Birth * +

Last 4 of SSN# *

Mailing Address (if different than service address)

Address

Street

City

State

Zip Code

Co-Applicant *

Yes

First Name *

Last Name *

Phone number *

Email Address *

Date of Birth * +

SSN Last 4 *

RACE & ETHNICITY DATA COLLECTION

Title VI of the Civil Rights Act of 1964 requires “Race and Ethnic” data collection from beneficiaries of federally assisted programs. Please note “Discloser Clause” below.

“The following information is requested by the federal government for certain types of loans and grants to monitor compliance with Federal Civil Rights laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in the evaluation of your application and the law requires that a program recipient may neither discriminate on the basis of this information nor on whether you choose to furnish it. However, if you choose not to furnish it, under federal regulations, this program representative is required to note race/ethnicity on the basis of visual observation or surname.”

Ethnicity (Mark only one) *

Hispanic or Latino

Not Hispanic or Latino

If you do not wish to provide the information, please check the box below: *

I do not wish to furnish this information.

Gender *

Male

Female

Please indicate you understand that you will receive your bills via email **If you are unable to receive bills via email please contact our office**

I understand that if my account becomes delinquent, fees will continue to accrue as long as the account is active

I understand that my deposit will be applied to the final bill after service is terminated. I also understand that I am responsible for promptly contacting RVSD if the property is sold, if I move, or if there are any 3rd party changes that may affect this account.

I understand and agree to comply with all conditions for water and/or sewer service as set forth in this agreement. I further agree to abide by all rates, ordinances and regulations pertaining to such service. I understand that RVSD will only allow the applicant(s) listed to make changes to the account

NOTE: A deposit will be required for all new accounts. Once you have submitted this form, please call the RVSD office at 605-393-1050 or come to the office located at 4611 Teak Dr to make arrangements for your deposit. Office hours are Monday-Friday 7 am to 5 pm. Your account will not activate until arrangements for your deposit are complete.

Renter Deposit = $100
Owner Deposit = $7.50 or $10
Owner Deposit New Construction = $292.50 *If new construction a meter will need to be installed once you take possession. Contact our office for a breakdown of new construction fees**

Signature Statement:

Providing the applicant and co-applicant names below constitutes signatures. Additionally, the applicant(s) certify that the information provided on this form is true and accurate and the applicant(s) agree to be financially responsible for all utility bill charges to include usage, late fees, reconnect fees and service fees as long as the bill remains in the applicants name.

Name *

Date * +

Co-applicant Name *

Date * +