Applications submitted after 4 PM will be processed on the next business day. Please see our list of office hours and holidays that may affect your application. Contract for Service – Existing Home or Business Utilities Commission, City of New Smyrna Beach, Florida | Phone (386) 427-1361 | Fax (386) 424-2713 | www.ucnsb.org Today's date: Month MonthJan Day Day16 Year Year2021 Requested Service Start Date: (required) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022 Applicant Information Name of Applicant: (required) Applicant is: (required) Owner Tenant Date of Birth: (required) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Social Security #: (required) Previous service with UC? (required) Yes No Previous Address (no P.O. Box): Street Address: City: State: AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code: Email Address: (required) Phone: Home Phone: (required) Cell Phone: Work Phone: Co-Applicant Information Name of Co-Applicant: Co-Applicant is: Owner Tenant Date of Birth: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Social Security #: Previous service with UC? Yes No Previous Address (no P.O. Box): Street Address: City: State: AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code: Email Address: Phone Home Phone: Cell Phone: Work Phone: Requested Service Address: Street Address: (required) City: (required) State: (required) AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code: (required) Service Address Type: (required) Business Residence Billing Address Information: (required) My billing address is the same as my requested service address. My billing is different from my mailing address. (Enter billing address below.) Bill Mailing Address: Street Address: City: State: AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip code: Service Options Service Options: (required) Electric Water Sewer Reuse (if available) Irrigation Meter Streetlight This is a rental property. Upon my request, I authorize UCNSB to turn on service in my name between tenants without making additional application. Yes, I authorize UCNSB to turn on service in my name between tenants without making additional application. Documentation Upload photo copies of driver’s license or other official state identification and proof of ownership, lease agreement or Notarized Account Representative Affidavit here. Identification Files must be less than 20 MB.Allowed file types: gif jpg jpeg png pdf. Proof of Ownership or Lease Files must be less than 20 MB.Allowed file types: gif jpg jpeg png pdf. Notarized Account Representative Affidavit Files must be less than 20 MB.Allowed file types: gif jpg jpeg png pdf. Customer Verification IF APPLICABLE, RESIDENTIAL HOUSEHOLD AFFIDAVIT: This is to certify that until the undersigned notifies UCNSB in writing, the electrical service provided to the above referenced account is exempt from the Florida Sales Tax for the following reasons: (1) the electrical service provided to this account will be used exclusively to service a residential household and the meter will not service any commercial or business activities. Commercial or business activities include but are not limited to, rental operations that cater primarily to transient guests (hotel, motels and room rentals), the provisions of day care facilities, and the performance of any activity that is not residential in nature. (2) The electrical service provided to this account will be used exclusively to serve common areas of residential housing complexes, and the meter will not serve any commercial or business activities such as vending machines, coin operated laundry facilities, sewage/lift station equipment, or any activity that is not residential in nature. (3) The electric service provided to this account will be used exclusively to serve a residential model home. The meter will not serve any commercial activity such as a sales or business office, or any activity that is not residential in nature. Customer Verification (initial): (required) Initial connect charge is $35 (reconnect fee is $50) and will be billed on the first billing statement to the customer. Photo copies of driver’s license or other official state identification and proof of ownership, lease agreement or Notarized Account Representative Affidavit are required. I hereby make application to the Utilities Commission, City of New Smyrna Beach (UCNSB), Florida for utility service and upon approval of this application, agree to abide by all UCNSB resolutions, tariffs, policies, procedures, rules and standards, and acknowledge and agree this contract is made subject to the provisions of UCNSB’s Rates, Charges and Fees and Services Policies and Customer Information Manual, the latter of which I have been provided, and incorporates such manual as part of this contract as it exists at the time of this contract and may be amended as per the last paragraph of said manual. I also acknowledge and agree that the undersigned, as a UCNSB customer, shall be liable for all applicable sales tax and agree that I will be personally responsible for the payment of deposit and/or utility bills rendered under this account. Name of Applicant Signifying Agreement: (required) Name of Co-Applicant Signifying Agreement: Leave this field blank