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Application for Automatic Reinstatement of Responsibility for Utility Billing Charges

  1. Upon receipt of this signed application, the City of Portage can automatically reinstate property owners or property managers to utility billing accounts when a tenant leaves. The city interrupts services when no billing information is received at the time of a final meter reading. This automatic reinstatement will avoid any such service interruptions (other than when water is turned off for non-payment). This is a free service that will be effective upon receipt of this form by the Treasury Office.

  2. Select the type of third party*

    Select one type only.

  3. By signing this agreement, you initiate Automatic Reinstatement of Responsibility for Utility Billing Charges and indicate that you understand that you must cancel this authorization upon sale of the property.

  4. 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.

  5. Treasury Staff only:

  6. Owner Cust. # ___________

  7. Processed by ______________

  8. Checked by _______________

  9. Leave This Blank:

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