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In consideration of the City of Victoria providing utility services of water, sewer, and storm water, I/we being the owner(s) and/or renter(s) of the real property listed above, affirms that all information on this application is true and correct. I/We will assume the full responsibility of all financial obligations at the above address. I/We have been informed that in the event of non-payment for any of the above-referenced utility services, the City of Victoria may assess said unpaid charges, penalties, and fees against the real property so served pursuant to Victoria Code of Ordinances, Chapter 26. The City of Victoria shall assess said unpaid charges by certifying the amount to the Carver County Auditor for collection as a real property tax.

Please be aware that if the prior owner of your property leaves an unpaid balance, this amount will be assessed to the property for collection with taxes. To avoid this, please contact your title company to verify that the final balance will be paid. You may contact the city to verify payment has been made.

This application will remain in effect until I/we have notified the city in writing to discontinue service. I/We agree to comply with the city ordinances that govern the use of these utilities. I/We agree to permit the authorized agents of the city free access to premises for the purpose of inspection, repair, replacement or service to the water meter and its components as needed.

LEAVE THIS SECTION BLANK IF YOU HAVE NOT SELECTED AUTOMATIC BILL PAYMENT.

I hereby authorize the City of Victoria and the financial institution named below to make debit entries from my bank account for the payment of my city utility bill. I understand that this authority will remain fully effective until I cancel my authorization by calling (651) 255-0923 or by sending a written notice, providing the city a reasonable opportunity to act upon my notice. I have the right to stop payment within seven (7) days of my billing due date, but I must notify the City of Victoria of this stop payment request. I understand that the City of Victoria reserves the right to terminate this payment plan or my participation in it. A $30 NSF fee will apply for items returned for non-payment.

If automatic bill payment is selected, all fields below must be completed. If you prefer, you may print and complete this form and mail to City of Victoria, Utility Billing, P.O. Box 36, Victoria, MN 55386 or drop off at Victoria City Hall.