Form Center

2. Date today:
   Date today:
3. TOB Employee :
5. Services requested to start on:
   Services requested to start on:
6. Choose one:

   1. New Account
   2. Transfer
   3. Prepay
7. Choose one: *

   1. Rent
   2. Own
   3. Property Manager
9. 1. Account Holder or Authorized Employee (please fill up)
11. Account #
13. Customer # (if available):
15. Name:*
17. Company Name:
19. Address:*
20. Mailing Address:*
22. Valid Picture ID:*
23. SSN or Tax ID:*
25. Mobile (for text):*
26. Phone (for calls):
27. Email:
29. 2. Traditional Customers Only (deposits, fees, and past due payments are required to start services)
31. Service Details:

    1. Electric
    2. Water
    3. Sewer
    4. Garbage
    5. Area Lights
32. Electric Deposit Amount:
33. Water Deposit Amount:
34. Sewer Deposit Amount:
36. TRANSFERS ONLY (fee and current bill must be paid):
38. Transfer from Account #:
40. Deposit Amount:
42. Apply $ to New Account:
43. Deposit:
44. Payment:
46. Past Balance:
47. + Deposit
48. + Transfer Fee
49. = TOTAL:
51. 3. Prepaid Customers Only
53. Moving from traditional billing to prepay?
    -- Select One --YESNO
55. Notification Information:
56. myUsage Login:
57. Password:
58. Low Balance Notification Amount:
60. Send the Following Notifications:

    1. Low Balance
    2. Daily Balance
    3. Recharge
    4. Pending Disconnect
    5. Disconnect
    6. Reconnect
61. Notification 1

    1. Email
    2. Email
    3. Email
    4. Email
    5. Email
    6. Email
62. Notification 2 (if available):

    1. Text
    2. -
    3. -
    4. Text
    5. -
    6. -
64. MyUsage Setup:
66. Deposit on File:
67. Balance on Current TOB Account:
69. Debt Recovery $:
70. Debt Recovery %:
72. Balance / Credit to MyUsage:
73. Date Calculated:
    Date Calculated:
75. Date Created on MyUsage:
    Date Created on MyUsage:
76. NS Deposit Applied as Payment?
    -- Select One --YESNO
78. Cycle 10?
    -- Select One --YESNO
79. Processed By:
81. 4. Please Check for USDA Reporting Purpose Only
83. Gender:

    1. Male
    2. Female
84. Race

    1. Asian
    2. Pacific / Islander
    3. Black / African American
    4. Two or more races
    5. Hispanic / Latino
    6. White
    7. Other
86. 5. Customer Agreement (this section must be initialed and signed by applicant)
88. Initial: *
    BY SIGNING THIS APPLICATION I AUTHORIZE THE TOWN OF BENSON TO USE MY INFORMATION TO DETERMINE MY DEPOSIT AND UTILITY ACCOUNT ELIGIBILITY.
89. Initial: *
    FOR TRADITIONAL CUSTOMERS SWITCHING TO PREPAY ONLY, I UNDERSTAND IF I WANT TO SWITCH BACK TO TRADITIONAL BILLING, A NEW DEPOSIT WILL BE REQUIRED.
91. Print Name: *
92. Date:*
94. DIGITAL SIGNATURE: *
    BY TYPING YOUR FULL NAME INTO THIS FIELD YOU ARE SIGNING THIS DOCUMENT.
96. Upload Lease OR Closing Document*
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit Submit and Print

* indicates a required field