Property Owner Acknowledgement Of Financial Responsibility And Assignment Of Billing Agreement
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1
2PROPERTY OWNER ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
AND ASSIGNMENT OF BILLING AGREEMENT
City of Victorville - Victorville Water District
14343 Civic Drive, Victorville, CA 92393
Phone: 760-955-5001
Please print in ink or type
CustomerService
victorvilleca.gov
Fax #: 760-269-0023
@
Service Location
Address:
Street
Apt, Unit, or No
City
State
ZIP Code
Assessor’s Parcel Number (APN):
Escrow Close Date
Move In Date
Property Owner or Authorized Representative/Agent
Name:
Email Address:
Mailing Address:
Street
Apt, Unit, or No
City
State
ZIP Code
Identification:
Customer ID Number (if existing customer)
State Driver License/ID Number
Telephone:
Service
Alternate
Fax
Business License Number
Expiration Date
1
Assignee/Applicant
(circle one): Tenant
Agent
Other:____________________________________
Name:
Email Address:
Mailing Address:
Street
Apt, Unit, or No
City
State
ZIP Code
Professional Business Card
Identification:
State Driver License/ID Number
Telephone:
Service
Alternate
Fax
Business License Number
Expiration Date
1
Requires copy of current authorized and executed contract/agreement establishing the relationship indicated including valid
signature(s) and date to be submitted with Utility Service Application and Agreement.
Form: POA 05/07/2013
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Parent category: Legal