Jacksonville, NC - Official Website

Name *

First Name Middle Name Last Name Suffix

Service Start Date *

Date

Phone number (daytime contact) *

Area Code Phone Number

Service Address *

Street Address

Street Address Line 2

Mailing Address (if different than service address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Alternate Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Valid email address

example@example.com

Date of Birth *

Date

Social Security Number *

Driver's License # and State Issued *

City & State of Birth *

Street Address

Street Address Line 2

City State / Province

Place of employment *

Work Phone # *

Mother's Maiden Name *

Relative's Name & Phone Number *

Please use a contact that does NOT live with you.

Owner, Landlord, Property Management *

Name

First Name Last Name

Date of Birth

Date

Social Security Number

Phone Number

Area Code Phone Number

Do you have any of the following at the service location? Please check all that apply.

In Ground Swimming Pool or Hot Tub Lawn Irrigation System Fire Sprinkler System Water Front Property

Does the service location have an alarm system? *

If you answer yes, you are required to fill out an alarm system registration application. This form is available online at jacksonvillenc.gov/AlarmRegistration, or fill out a form at City Hall.

Would you like to have a soft credit check performed ($3.50) for possible waiver of all or part of the required utility deposit? *

Lease or Purchase Papers *

Browse Files

Please upload a copy of your lease or purchase papers. Send only the pages that contain the service address and signatures.

Photo ID *

Browse Files

Please upload a copy of a valid government issued photo identification.

Entering your name into the signature line of the electronic application indicates that you have provided correct information and are establishing utility service with the City of Jacksonville. It also indicates that you understand that the request of SSN# is permitted by NC State Law & will be used to facilitate collection of unpaid delinquent water bill accounts. This will allow the City to claim payment of an unpaid water and sewer bill from a State income tax refund that might be owed. You also understand that you provided a photo ID and drivers license number which is a requirement for utility service.

Applicant Signature *

Clear

Applicant Signature *

Co-Applicant Signature

Date *

Date

E-Notification:

We offer a few different billing options for your convenience. Go green by enrolling in ebill. You can add an option or modify your account at any time by enrolling in our Customer Portal at www.jacksonvillenc.gov.

Jacksonville offers easy ways for you to pay your utility bill.

Payment for your utility bill is accepted:

Automatic bank withdrawal: Choose your own draft date with credit card or echeck auto pay. Enroll now in our Customer Portal at www.jacksonvillenc.gov.

By mail: Through the mail, use the return envelope with the address provided: City Hall / Utilities Billing P.O. Box 128 Jacksonville, NC 28541-0128

By phone: Call 910 938-5248. Please have billing information available when you call.

Drop box: A drop box is available at City Hall for after-hours payment and will be applied the next business day.

In person: You may pay your bill in person at: City Hall / Utilities Billing 815 New Bridge St. Jacksonville, NC 28541

Online: Online Bill Pay now offers customers the option to automate monthly payments! www.jacksonvillenc.gov

Your signature below indicates that you, the applicant, have read and understood the following:

-If your home has a Burglary or Robbery Alarm System, it must be registered by filling out the alarm system registration form. An annual registration fee of $10 is required for residential and commercial sites. Please note that if police respond to an unregistered alarm, you will be fined a minimum of $100.

-The City of Jacksonville does not require you to be home when service is established. It is your responsibility to ensure that all water faucets are off and there are no leaks during the cut on procedure. If you have a hand gate valve on your waterline it is highly recommended that the valve is in the off position. If there is any water running inside at the time of cut on, the water will be turned off at the meter and a tag will be left on the door instructing you to call the Utility Billing Office. ($25 call back fee will be applied if second trip required.) The City is not responsible for any damage that may be cause by water running inside the home.

-You are responsible for any and all City of Jacksonville utility bills generated at the address of service unless notice of termination is received by the City of Jacksonville Utility Billing Office. Monthly Charges will continue as long as service is furnished in applicant’s name at the service address. Charges for water, sewer, and sanitation services continue when meter is turned on whether used or not. The City of Jacksonville must be notified when service is to be discontinued.

-There will be a 10% late penalty applied to your account if balance is not paid within 10 days of due date. There will be a $55 suspension fee applied to your account if previous balance is not paid within 10 days of your current bill date.

-There is a $55 after hours charge for service provided after normal business hours.

-A meter tampering charge of $125 will be applied to your account if you, for any reason, tamper with the City’s meter. Call 910-938-5248 to request water turn on or off at the meter.

-If your water has been suspended for nonpayment, you will be required to pay past due bills plus a suspension fee to a Customer Service Representative to initiate a reconnect service order.

-When calling to inquire about an account, you will be required to answer a minimum of two security questions that are indicated on the front of this application before any information is released.

-Delinquent accounts with the City may be subject to cut-off of utilities services at any property or premises. Delinquent accounts must be paid in full to re-establish service.

-Returned or dishonored checks or ACH/credit card drafts (for any reason) will be assessed a $25 processing fee. The City will electronically debit your account for the amount owed.

- Deposits will be refunded when service is terminated or after 2 years of satisfactory payment history.

Applicant Signature *

Date *

Date

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Co-Applicant Information

Additional Information

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Billing and Payment Options

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