• Phone: (812) 358-3654
  • Email us: mail@jacksoncountywater.com
  • Working Hours: 08:00am -4:30pm

Service Application – Rental

Easy and Convenient

 
Opening Times
Monday – Friday:
08:00am – 4:30pm
 
Our Location
P.O. Box 56
1119 W Spring Street Brownstown, IN 47220
 
Customer Service
Phone: (812) 358-3654

Rental Application

Rental App
Applicant Name
Applicant Name
First
Last
Receive Bills via Email
Mailing Address is same as Service Address
Other Mailing Address
Other Mailing Address
City
State/Province
Zip/Postal
Type your Drivers License Number exactly as it appears on your Drivers License
Co-Applicant
Co-Applicant Name
Co-Applicant Name
First
Last
Type your Drivers License Number exactly as it appears on your Drivers License

Maximum file size: 62.91MB

Maximum file size: 62.91MB

Your Previous Address
Your Previous Address
City
State/Province
Zip/Postal
INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The information requested by the Federal Government in order to monitor compliance with the Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish, we are required to note the race/ national origin of individual applicants on the basis of visual observation or surname.

Demographics Declined:
Gender:
Ethnicity:
Race:

PLEASE SIGN AND SUBMIT APPLICATION

In order to obtain service with the Jackson County Water Utility all Rental applicants will need sign, date and submit this form.

Confirmation
Please select signing date from the Calendar Pop-up
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