Account # ___________________
11701 Community Center Dr.
PO Box 330061
Northglenn, CO 80233
Phone: 303-450-8770
FAX: 303-450-8708
email: [email protected]
Owner Occupied _____ Rental Property _____
Other ________________
Effective Date: _____/_____/_________
Address of Northglenn Property: _____________________________________________
Owner of Record:
Mailing Address:
Phone #:
Authorized Agent [ ] OR Tenant [ ] (Tenant is Not Authorized to make payment arrangements)
Please complete a separate form if the Authorized Agent is different than the tenant or is a Management Company.
Phone #:
The City of Northglenn requires that utility bills for residential properties be issued in the name of the owner or in the
name of an individual authorized by the owner. An Authorized Agent is approved to receive utility bills and to make
payment arrangements on delinquent accounts in accordance with our policies. A Tenant is approved to receive utility
bills but is not allowed to make payment arrangements. A Tenant may also be designated as an Authorized Agent.
PLEASE NOTE: Since a property can be liened for unpaid utility bills, the owner is ultimately responsible for all
utility charges.
I understand that if I (the owner) live more than 25 miles outside the boundary of the City of Northglenn, an
Authorized Agent is mandatory and then responsible for receiving notices and court processes for violations of the
Housing Code, Building Code, Fire Code, Nuisance Ordinance, Zoning Ordinance, or any other Ordinance of the City
of Northglenn pertaining to this property. The Authorized Agent for this property is 18 or more years of age and either
resides, or is customarily present in an office, within 25 miles of the City of Northglenn. I understand that the City
of Northglenn must be notified of any change(s) to the above information no later than thirty (30) days after the
Any person who fails to register as required by Section 20-2-1(a) shall be subject to a civil penalty of not more
than $300.00 per day for each day said person remains unregistered up to a total of $15,000.00.
Signature of Owner: ________________________________________ Date: ________________