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PROPERTY AND PROPERTY OWNER INFORMATION

Effective Date*
Effective Date
Property Address*
Please Select One*
1. Owner
2. Renter or Land Contract
Will you be residing in the property or renting it out?
Property Owner First Name
Property Owner Last Name
Property Owner Address
(please include City, State, and Zip code)
Lease Period
Lease Period Start Date
—
Lease Period End Date
Copy of Lease Agreement
Your lease agreement MUST be submitted with your application.
Property Owner Acknowledgement
As owner of the service address, I understand and agree that I am liable for any and all outstanding utility charges provided to that address. As the owner, I also understand that unpaid balances for utilities can and will be certified to the taxes for this property if I do not pay them.
Property Owner Signature
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Applicant First Name*
Applicant Last Name*
Applicant Phone Number*
No dashes
Last 4 digits of SSN*
No dashes
Applicant Date of Birth*
Applicant Date of Birth
Applicant E-mail Address*
Applicant Preferred Method of Contact*
Is the applicants mailing address different than the service address?*
1. Yes
2. No
Applicants Mailing Address
(please include City, State, Zip code)
Is the applicant employed?*
1. Yes
2. No
3. Self-Employed
4. Retired
Applicants Employer*
Applicants Employer Phone Number*
Employer Address*
(please include City, State, and Zip code)
Does the employer withhold City tax?
1. Yes
2. No
3. I don't know
What is the Applicants source of income?
What is the name of the business?
What is the address of the business?
(please include City, State, and Zip code)
What is the phone number of the business?
When was the business established?
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Are there adults other than the Applicant and Co-Applicant living in the household?*
1. Yes
2. No
Please list the name, date of birth, and last four of the social security number of any adults other than the Applicant and Co-Applicant living in the residence.
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What is the Applicants last address?
(please include City, State, and Zip code)
Has the Applicant, Co-Applicant, or anyone else in the household had previous utility service in their name in the City of Monroe?*
1. Yes
2. No
List the person(s) that have had previous utility service in their name in the City of Monroe.
Where?
List street Address
What year?
Is the Applicant, Co-Applicant, or anyone else in the household presently filing or have they previously filed with our tax office?
1. Yes
2. No
List the person(s) that have previously filed with our tax office.
What years?
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Does anyone residing at this location own a rental property?*
1. Yes
2. No
Where are the rental properties located?
(please provide the name of who owns the properties, the addresses, city, state, zip, and when the properties were initially rented)
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Utility Deposit Required
If you selected RENTER or LAND CONTRACT above, please contact the City of Monroe at 513-539-7374 x 1000 to pay the $200 utility deposit. Utilities will not be transferred into your name until the lease agreement and deposit have both been received.
Utility Agreement
The undersigned agrees to pay each month, upon proper billing, the charges for water and/or sewer, storm water and refuse service used at the rates established for the system on which the property is located. The Applicant, by signing this application, agrees to be bound by all the provisions and the Rules and Regulations adopted by the City of Monroe, Ohio, as they exist and as amended from time to time. Upon vacating the premises, the Applicant further agrees to give proper notice to the Utility Department, and all charges against said property, upon proper billing, shall be paid in full. The Applicant authorizes access to meters at any time for all purposes deemed by the City of Monroe.
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Notification of Tax Filing Requirement
All residents living in Monroe (including part year residents) are required by the Ohio Revised Code Section 718 and Monroe Ordinance No. 2015-40 to file a Local return. A return is required even if tax is fully withheld. Retired residents are required to file every third year. (2015, 2018, etc.). Please complete the resident account registration form and submit it with the Annual return.
Tax Declaration
Under penalties of perjury, I declare that I have examined the information on this form, and to the best of my knowledge and belief, the information provided herewith is true, correct, and complete.
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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.
1. I agree.
Applicant Electronic Signature*
Date*
Date

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