Deposit Assistance Program
________________________________has
been approved for basic utility connection and
(applicant)
service at __________________________________________ provided that the required utility
(unit address)
deposit(s) in the total amount of $____________ is/are paid in full by _________________.
(date deposit(s) is/are due)
Types of utilities requiring deposits:
_____ WATER Required Deposit Amount: __________
_____ GAS Required Deposit Amount: __________
_____ ELECTRIC Required Deposit Amount: __________
Total amount of outstanding balances currently owed by this client: _________________.
Please provide a brief description of any approved payment arrangements with this client:
________________________________________________________________________
_______________________________________________________________________.
Is the client current in all payment arrangements: ______ YES ______ NO
BY SIGNING AT THE BOTTOM OF
THIS FORM YOU ARE GUARANTEEING THAT YOU HAVE READ AND AGREE TO THE FOLLOWING
CONDITIONS:
_______________________________________________
hereafter referred to as company is
willing to
(name of utility company)
accept all or partial utility deposit(s) for the above unit from the Central Iowa Regional Housing Authority. The company agrees that any amount of the required utility deposit(s) not provided by CIRHA is/are the responsibility of the client. The company understands that if approved for deposit assistance, the client will provide the company with a CIRHA Deposit Assistance Voucher stating the amount that will be paid by CIRHA and the date the actual check will be mailed to the company. The company understands that this deposit assistance is part of a grant program and that any and all future refund of this/these deposit(s) will be paid directly to the client. The company also understands that the Central Iowa Regional Housing Authority carries no responsible for the actions (financial or otherwise) of the client or guests of the unit. All claims for unpaid bills are the sole responsibility of the client.
CHECK MADE PAYABLE TO ________________________________________________
MAILING ADDRESS _______________________________________________________
_________________________________________ ________________________
COMPANY REPRESENTATIVE SIGNATURE DATE
__________________________________ __________________________________
PRINT NAME OF SIGNATORY TITLE OF SIGNATORY
Please return this form to the applicant or CIRHA
1201 Gateway Drive Fax: (515) 986-1883
Grimes,