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Application For Gas & Water Utility Service
City of LaCygne
P.O. Box 600, 210 Commercial, LaCygne, KS 66040
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Name of Applicant __________________________________________________
Social Security Number ______________________________________________
Location of Service __________________________________________________
Owner of Property other than Applicant __________________________________________________
Place of Employment ________________________________________________________________
Mailing Address of Applicant __________________________________________________________
Home Phone ____________________________ Cell/Work Phone ___________________________
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Type of Service _____________________________ Deposit Paid ____________________________
Date Service Started________________________ Date Service Ended _______________________
All Applicants are required to place the following utility deposits with the City of LaCygne:
Water meter, $75.00; Residential gas meter, $200.00; Commercial gas meter, $350.00. Interest payments are made annually and deposits will be refunded in accordance with Sections 14-113 and 14-307 of the Code of LaCygne.
I understand the statement of account will be mailed to me the 1st day of each month. Payment of account may be made at City Hall, P.O. Box 600, LaCygne, KS 66040, or at Labette Bank in LaCygne and are due by the 15th of each month. A late charge will be added if not paid by the 15th of the billing month. Failure to pay this statement will result in termination of services. In order to re-establish service a reconnect fee of $25.00 per meter plus the total outstanding account must be paid. Re-connects due to nonpayment of account may only be done from Monday thru Friday between the hours of 8:00 a.m. and 4:30 p.m..
Do you want an Excessive Flow Valve? Yes _____ No ______
*Applicant Signature for Excessive Flow Valve
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Applicant ___________________________________________________
Date __________________________
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