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2. Date of Service*
   Date of Service
3. Purchased or Renting*
   -- Select One --PurchasedRenting
4. Please Note:

   If you are renting property, a Tenant Deposit in the amount of $200 is due to the City of Dyersville prior to service connection. Please contact city hall to make payment.

6. Name(s) As To Appear on Account*
7. Spouse/Fiance/Signifcant Other Not Listed on the Account
9. Address Moving Into*
11. Mailing Address if Different from Service Address
13. Address2
15. City
16. State
17. Zip
19. Phone/Cell No.*
20. Additional Phone No.
21. Email Address*
23. Social Security No.
24. Date of Birth*
    Date of Birth
25. Spouse Soc. Security No.
26. Spouse Date of Birth
    Spouse Date of Birth
28. Business Fed. ID No.
29. Previous Address
    If you need service disconnected at another address, please provide address and date of disconnection.
31. Paperless Billing*

    1. Yes
    2. No

    Check yes or no if you would like your utility bills and notices emailed and not receive a paper copy in the mail.  

33. Automatic Bank Withdrawl Form
    Authorization for Automatic Bank Withdrawl

    If you are interested in having your bill automatically deducted from your checking or savings account, please click the link above.
35. Emergency Notification System
    Smart 911 Emergency Notification Link

    If you want to be added to the Dyersville emergency notification list, please click the link above.  This system will alert you to snow emergencies, water issues, and other emergency events.  Please be sure to opt in for the "City of Dyersville".

37. Proof of identification
    Please upload a copy of a government issued photo I.D. If a government photo I.D. is not available, please upload another type of photo identification.
39. Online Deposit Payment Portal

    If you would like to pay your Tenant Deposit online, please use this link. Online Deposit Payment Link.  Please note that processing fees are added to all credit card payments.

    When using the link, you will need to create an online account to make the payment. 

    After creating your account, click on "Utility Account Info / Payments / Connections / Disconnections", then select "Connections" and follow the step-by-step instructions.  

    If you have completed and sent this application for services, you will not need to do that step again.  

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field