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Application & Agreement for Residential/Commercial Utility Service

  1. City of Vermillion Logo

  2. APPLICATION & AGREEMENT FOR RESIDENTIAL/COMMERCIAL UTILITY SERVICE

    NOTE: PAYMENT OF ALL DEPOSITS AND FEES ARE DUE BEFORE SERVICE WILL BE ESTABLISHED.

  3. mm/dd/yyyy

  4. Driver License or State ID Number

  5. List the state that issued ID.

  6. MON-FRI 8AM TO 4PM, EXCLUDING HOLIDAYS

  7. If you do not have a check, attach a bank record that includes a complete account number and bank routing number. For further questions, contact the Finance Office at 605-677-7056.

  8. Utility Deposit  Fee Schedule 2019

  9. Acknowledgement of Fees*

    I acknowledge that completing this application will start all applicable services (electric, water, sewer, recycling, security light and/or mobile home fees) provided to this address and I am personally responsible for all charges including any late fees. Utility services will continue in my name until I request them to be terminated unless service is disconnected for nonpayment of the utility account as outlined by our disconnect policies. All applicable residential deposits will be applied onto my final bill after service is disconnected. As a utility customer, I agree to comply with all City ordinances and will provide access to the utility meters for reading and/or maintenance.

  10. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  11. FOR OFFICE USE ONLY

  12. Account Number:

  13. Deposit Amount:

  14. Receipt Number:

  15. Outstanding Accounts:

  16. Leave This Blank:

  17. This field is not part of the form submission.