Contract for Service – Existing Home or Business

Utilities Commission, City of New Smyrna Beach, Florida
Phone (386) 427-1361 | Fax (386) 424-2713 | www.ucnsb.org
Date:
Requested Service Start Date:
The Utilities Commission, City of New Smyrna Beach is open at the following times; 8 a.m. to 5 p.m., Monday - Friday
UC Holidays (Customer Service and Administrative Offices closed):
New Year's Day, Martin Luther King Day, Presidents' Day, Memorial Day, Independence Day, Labor Day, Veterans' Day, Thanksgiving Day, the day after Thanksgiving Day, Christmas Eve and Christmas Day
Requests made outside these hours or during a holiday will not be received until the next regular working day/hour.
Applicant
First Name:
Middle Initial:
Last Name:
Applicant Is:
Owner  Tenant
D.O.B:
Social Security #:
Phone#:
Home:
Cell:
Work:
Previous Address: (no P.O. Box) 
*E-Mail:
City:
State:
Zip Code:
Previous service with UCNSB?
Yes No
Co-Applicant
First Name:
Middle Initial:
Last Name:
Co-Applicant Is:
OwnerTenant  
D.O.B:
Social Security #:
Phone#:
Home:
Cell:
Work:
Current Address: 
*E-Mail:
City:
State:
Zip Code:
Previous service with UCNSB?
Yes No
Required Documentation
Photo copy of Driver’s License or ID:
Proof of Ownership or Lease Agreement or Notarized Account Representative Affidavit:
Requested Service Information
Service Address: 
Service address is:
Business Residence
City:
State:
Zip Code:
Billing Information
Billing Address:
City:
State:
Zip Code:
Service Options:
Electric  Water  Sewer  Reuse(if avail.)  Irrigation Meter  Streetlight
 
 
This is a rental property. Upon my request, I authorize UCNSB to turn on service in my name between tenants
without making additional application.
IF APPLICABLE, RESIDENTIAL HOUSEHOLD AFFIDAVIT: This is to certify that until the undersigned notifies UCNSB in writing, the electrical service provided to the above referenced account is exempt from the Florida Sales Tax for the following reasons: (1) the electrical service provided to this account will be used exclusively to service a residential household and the meter will not service any commercial or business activities. Commercial or business activities include but are not limited to, rental operations that cater primarily to transient guests (hotel, motels and room rentals), the provisions of day care facilities, and the performance of any activity that is not residential in nature. (2) The electrical service provided to this account will be used exclusively to serve common areas of residential housing complexes, and the meter will not serve any commercial or business activities such as vending machines, coin operated laundry facilities, sewage/lift station equipment, or any activity that is not residential in nature. (3) The electric service provided to this account will be used exclusively to serve a residential model home. The meter will not serve any commercial activity such as a sales or business office, or any activity that is not residential in nature.
Customer Verification (initial)
Initial connect charge is $35.00 and (reconnect fee is $50) and will be billed on the first billing statement to the customer. Photo copies of driver’s license or other official state identification and proof of ownership, lease agreement or Notarized Account Representative Affidavit are required.
 
I hereby make application to the Utilities Commission, City of New Smyrna Beach (UCNSB), Florida for utility service and
upon approval of this application, agree to abide by all UCNSB resolutions, tariffs, policies, procedures, rules and standards,
and acknowledge and agree this contract is made subject to the provisions of UCNSB’s Rates, Charges and Fees and Services
Policies and Customer Information Manual, the latter of which I have been provided, and incorporates such manual as part
of this contract as it exists at the time of this contract and may be amended as per the last paragraph of said manual. I also
acknowledge and agree that the undersigned, as a UCNSB customer, shall be liable for all applicable sales tax and agree that
I will be personally responsible for the payment of deposit and/or utility bills rendered under this account.
*All fields marked with a red asterisk are required
Applicant/s Signature
By clicking submit I agree to digitally signing this document and agree to any and or all Terms and Conditions that may apply.
 
     
 
 
 
 
 
Internal Use
To be completed by UCNSB:
Date and Time Submitted
 
Customer ID
Location ID
Start Date
Deposit (if required) $
Deposit due date