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2. Date*
   Date
4. Account Number:*
5. Account Name:*
7. Date of Birth
8. Email
9. Phone Number

11. Service Address:

13. Address
15. City
16. State
17. Zip Code

19. If applicable

21. Co-applicant's Name:

23. First Name
24. Last Name
26. Phone Number*
27. Email Address*
29. Date of Birth*

31. Note: This discount for water, sewer, and garbage will be given on the next billing following receipt of the application. The discount will not apply to any billing prior to the date the application is received by the City. Please attach a copy of "proof of age" by submitting a valid United States driver's license, identification card, passport, or Mexico Matricula Consular.

33. Upload Texas ID or Driver License*
34. Upload Texas ID or Driver License

36. My name is ____________________________________________. I am 65 years of age and the address above is my residence. I understand that the discount is only for senior citizen residents over 65 years of age, with singlefamily water, sewer, and garbage services in their name, whether owner or non-owner. 

38. 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.
40. Electronic Signature
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field