Forms

FORMS

Applications For Service

Applicants must contact the PSD #4 Office at 304-379-3130 (Option 2) before submitting a service application. PSD #4 serves a rural area, and water service is not available at all locations within our service territory. Office staff will verify service availability for your property and discuss any requirements or arrangements needed before service can be established.

Service Application
A valid government-issued photo ID is required when submitting this application. A security deposit of $59.77 must also be paid at the time the application is submitted.
Required Contact Prior to Application Submission

New Tap Application
A valid government-issued photo ID is required with this application.
A Tap Fee and Deposit totaling $359.77 must be paid at the time the application is submitted.
Water service must remain active and in good standing for a minimum of 36 consecutive months before a service disconnection request may be made.
Important:
The $300.00 Tap Fee is non-refundable once installation work has begun.
Communication with the PSD #4 Office is required during the application process.
If you need to make special arrangements for service, please contact our office at 304-379-3130 and select Option 2.

Other Forms

Leak Adjustments and Deferred Payment Agreements are not automatically granted and are subject to review and approval by PSD #4.

Leak Adjustment Request
Leak adjustments will not be granted for excessive water usage resulting from conditions that should be reasonably detected and corrected by the customer, including but not limited to
Running or leaking toilets (commodes)
Dripping faucets
Exterior faucets or hose bibs
Yard hydrants
Malfunctioning appliances
Similar plumbing issues or equipment failures
All leak adjustment requests are subject to review and approval by the PSD #4 Water Board. Approval is not guaranteed.

Deferred Payment Agreement
Please contact the PSD #4 Office to obtain a Deferred Payment Agreement Application. This form is not available for digital download or online submission and must be obtained directly from our office.
Eligibility Requirements
Customers requesting a deferred payment agreement for a past-due balance must meet all eligibility requirements established by PSD #4. Supporting documentation may be required as part of the review process.
Agreement Terms
Customers approved for a deferred payment agreement must comply with all terms and conditions of the agreement. Failure to do so may result in additional charges, loss of deferred payment privileges, service disconnection, or other actions permitted under PSD #4 policies and applicable regulations.
All deferred payment agreements are subject to PSD #4 review and approval

Account Holder Trasfer
To comply with Rules and Regulations, utility accounts can only be transferred to a surviving spouse. For all other situations, a new account must be established by submitting an application and paying the applicable deposit fee.
Discontinue Service Request

If a Digital form request is not filled out, please follow the link and fill out the paper copy.

Discontinue Service Request
Are you moving or need to disconnect your water service?
Please complete the Service Disconnection Request Form located at the bottom of this page. If you are mailing or emailing your request, a copy of the account holder's valid government-issued photo ID must be included.
Completed forms and supporting documentation may be submitted using the contact information provided above.
Please note: Requests cannot be processed without proper identification from the account holder.

Account Holder's Name *
Account # *
Discontinue Date *
Select day water service will be turned off.
Service Address *
Address to be disconnected
Select country/region
Phone *
Email
Forwarding Address *
Address remaining deposit (if there is one) will be mailed to.
Select country/region
File Upload *
A government-issued photo ID required of account holder to make form valid.
Upload File
Up to 20 MB