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2. Nursing Home Status will only apply to permanent residential homes with a current utility account which is owned by a person living alone, that has been confined to a nursing home or related facility, whose account is current. Nursing home status shall continue until that owner returns, becomes deceased or someone takes possession of the dwelling.
4. Date Nursing Home Status Requested to Begin*
   Date Nursing Home Status Requested to Begin
6. Account Holder's Full Name*
8. Account Number*
10. Service Address*
12. City*
13. State
14. Zip Code
16. Mailing Address*

    While you are away

18. City*
19. State*
20. Zip Code*
22. Phone Number*

    In case we need to contact you while you are away. 

23. Email Address

    In case we need to contact you while you are away.

25. Nursing Home*
27. Electric and Water Services will remain on and a monthly bill of $38.78 plus usage (inside city) or $35.41 plus usage (outside city) must be paid each month. The minimum monthly charges break down as follows:
29. Inside City

    Electric                      $9.40

    Water                         $13.19

    1/3 Sewer                   $7.61

    Garbage                     $8.58

    Total Base Charges $38.78 Plus Usage

30. Outside City

    Electric                      $9.40

    Water                         $16.49

    1/3 Sewer                   $9.52

    Garbage               

    Total Base Charges $35.41 Plus Usage

32. I understand that I must give at least a seven-day notice before returning so that my account may be taken off nursing home status. I also understand that the City of Bartow is not responsible for any electrical problems or water damage from services being left on while I am away.
34. Customer's Signature*
35. Acknowledgement /Consent*

    1. This is My Signature / I Agree

    By Checking this box, I acknowledge all information provided is true/correct including my provided signature and that I have read, understand and agree to the terms and conditions of this application.

    
    

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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

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