Service Requested in the Name of:
Requested By:        Applicant is the: Owner     Tenant
Drivers License #:        Date Of Birth:
Address of Service:
Mailing Address: City: State: Zip Code:
E-mail Address:        E-Bill/Paperless Bill: Yes     No
Contact Numbers:     Cell Phone      Phone
Service address is a: Residence    Business        Applicable Rate Schedule:
RESIDENTIAL HOUSEHOLD AFFIDAVIT: This is to certify that until the undersigned notifies KEYS in writing, the electrical service provided to the above referenced account is exempt from Florida's Sales Tax for the following reasons: (1) The electric 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)
Service fee is $35.00 and will be billed on the first statement billing to the customer. Photo copies of identification and proof of occupancy on file with KEYS.
Deposit Required       Start Date:
Deposit Payment Credit/Debit Card Information (please provide only if deposit payment is required):
Credit/Debit Card Number:    Expiration Date (MM/YY):
Credit/Debit Card Security Code: *Credit/Debit Card payments will be assessed a transaction fee for processing.
I hereby acknowledge and agree this contract is made subject to the provisions of the Keys Energy Services Customer Service Policy Manual, 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 KEYS customer, shall be liable for all applicable sales tax. The undersigned customer hereby grants the Utility Board of the City of Key West a security interest in the service deposit provided for under this agreement to secure payment and performance of all the debts and obligations arising from the provision of the Utility Board services to the customer in the ordinary course of business. The Utility Board will keep possession of the deposit and will refund the deposit only after all bills charged for services rendered have been paid by the customer. The customer's deposit will first be applied to any outstanding bills owed by the customer with the remaining balance, if any, being refunded to the customer.
The above customer and the Utility Board have duly entered in this agreement on
I ACCEPT - I understand that by checking the box next to the words "I ACCEPT" and typing my name below, I am signing this document electronically.
Customer Signature:
                                             KEYS Use Only
KEYS Representative:
Account No.:
Customer No.:
Form last revised: 9/20/15