Date Requested to Start New Service:

Residential Name: Phone:

Service Address:

Service City: State: Zip Code:

Mailing Address:

City: State: Zip Code:

Social Security No.: Drivers License No: State:

Contact Email:

Co-Applicant Name: Phone:

Co-Applicant Email:

Social Security No.: Drivers License No: State:

Landlord Name if you Rent: Phone:

I acknowledge, the Inman-Campobello Water District has provided me with a water rate schedule of fees. I have been advised I will receive a monthly bill with a due date of 20 days from the date of the bill. Should I not receive a bill, I will be responsible to contact the ICWD Office to verify the bill amount and the due date and will not hold the ICWD responsible for bills that I did not receive due to U.S. Postal deliveries.

I agree to pay all charges incurred until I have given notice to discontinue my service with the Inman-Campobello Water District. I understand if the balance on my account reflects a past due amount and my account has been charged a non-payment fee, my service will be subject to disconnection. The past due amount and the non-payment fee must be paid to have service restored or continued. I agree to pay all fees and costs incurred if collection procedures become necessary to satisfy past due balances for service.

By signing this application for water service, the applicant agrees to pay all cost of collection of the applicant's unpaid bills. The Inman-Campobello Water District has the right pursuant to the South Carolina Setoff Debt Collection Act to collect any sum due and owed by the applicant through offset of the applicant's state income tax refund. If the Inman-Campobello Water District chooses to pursue debts owed by the applicant through the Setoff Debt Collection Act, the applicant agrees to pay all fees and costs incurred through the setoff process, including fees charged by the Department of Revenue, the South Carolina Association of Counties, the Municipal Association of South Carolina, and/or the Inman-Campobello Water District. If the Inman-Campobello Water District chooses to pursue debts in a manner other than setoff, the applicant agrees to pay the costs and fees associated with the selected manner as well.

Date: ______________   Signature: _______________________________________________

Required Documents for New Service: $30.00 Non-Refundable New Service Fee and Drivers License