Section 1 of 1 in this document

Application For Water, Sewer, & Garbage Service

City of Bloomington, IL

A VALID PHOTO ID IS REQUIRED FOR EACH RESIDENTIAL APPLICANT (State License, ID, or Passport). BUSINESS APPLICANTS REQUIRE A VALID TAX FORM.

Full Name / Business Entity

Phone Number

Date Service To Begin

Occupied By:

Owner

Tenant

Landlord Information

Phone Number

Utility Insurance

Leak Protection insurance is 85 cents per month and provides up to $2,500 in leak protection coverage. Please choose an option below:

Please Add Utility Insurance To My Account

Please Remove Utility Insurance From My Account

City Code Chapter 27 Section 31

Water service may be disconnected and a delinquency fee of $50 assessed if payment is not made within 30 (thirty) days of the due date.
A penalty of 10% shall be assessed if payment in full is not received by the due date.
Unpaid balances may be transferred to service accounts for other premises in the same property owner’s name.
Damage to water lines and/or personal property damage may occur when water service is reconnected.

Upload Valid ID Image (State Issued Driver’s License, State Issued Photo ID, or a Passport)

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I have read, understand, and acknowledge the foregoing and agree to abide by all applicable rules and laws I understand that failure to pay my bill on time may result in disconnection of services. I further agree to hold the City of Bloomington harmless and waive any and all claims related to disconnection or reconnection of water service including potential damage to water lines and/or personal property. By signing this application, I certify that the information provided is true and correct.

Application For Water, Sewer, & Garbage Service

City of Bloomington, IL

Service Address

Mailing Address

Date Service To Begin

Occupied By:

Landlord Information

Landlord Name

Landlord Address

Utility Insurance

Leak Protection insurance is 85 cents per month and provides up to $2,500 in leak protection coverage. Please choose an option below:

Upload Valid ID Image (State Issued Driver’s License, State Issued Photo ID, or a Passport)

Sign Here