Village of Chapin
510 Everett Street
P.O. Box 213
(217) 472-3111
Application for Water Service
Requested Service Date ____________________________________________________
Name __________________________________________________________________
Date of Birth ____________________________________________________________
Driver’s License # ________________________________________________________
Spouse/Occupant(s) _______________________________________________________
Driver’s License # ________________________________________________________
Service Address __________________________________________________________
Mailing Address __________________________________________________________
Telephone Number (Home, Work & Cell) _____________________________________
Emergency Contact Person & Telephone ______________________________________
Homeowner Yes / No
Landlord Name __________________________________________________________
Address ________________________________________________________________
Telephone Number________________________________________________________
Note: A 10% penalty shall be added to the outstanding balance of each bill unpaid by the 20 th day of each month. In addition to said penalty, a $10.00 administrative fee will be charged to all accounts that are delinquent for more than thirty (30) days and that have been mailed a notice of delinquency by the Village. Service shall not be reconnected until all delinquent charges, current charges for combined service, fees and penalties on all unpaid charges, and a $75.00 reconnect fee for future service has been paid to the Village.
___________________________________________ ______________________
Signature Date
For Office Use
Account #_________________________ Route #___________Sequence# ________
Meter # ________________________ Meter Reading ___________________________
Deposit Amount______________________ Date Paid ____ __________________