CUSTOMER SERVICE DEPARTMENT
8570 EXECUTIVE PARK AVENUE TENANT AUTHORIZATION FORM
FAIRFAX, VA 22031
www.fairfaxwater.org
(Updated 3/9/2022)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Office Use Only
Lien Offset Received Cash Check Portal Speedpay Lien Offset Waived
Amount Received $____________ Account Number ___________________ Received By ___________________
Service Address _________________________________________ Service Start Date __________________________
The following tenant(s) have entered into a lease agreement for the referenced service address and is/are authorized to
obtain services from Fairfax Water at this address as my tenant(s).
Tenant Information - Please print the first and last name of each tenant (over age 18) on the lease agreement.
_________________________________________ _________________________________________
_________________________________________ _________________________________________
Contact Information
Phone ___________________________________ Email _______________________________________
• Lien Offset may be waived for tenants who receive need based local, state, or federal rental assistance.
If your tenant
receives rental assistance, please provide documentation with this form.
Property Owner/ Authorized Agent Information - Please provide first and last name, mailing address (different from the
service address) and contact information. Authorized agents must submit a copy of the property management agreement with the
tenant authorization form
Prope
rty Owner or Authorized
Agent ___________________________________________
Address _________________________________________________________________
Phone
___________________________________ Em
ail _______________________________________
By signing this form, I acknowledge, as the owner or authorized agent
of the service address listed above, I am
responsible for any unpaid balance for this account, after Fairfax Water has made a reasonable effort to collect from the
aforementioned tenant(s). If signing as an agent, he/she is authorized to endorse this document, on behalf of the owner.
Signature _________________________________________ Date ________________________
Propert
y Owner or Authorized Agent
For more information, visit fairfaxwater.org. For one-time payment, visit FWcustomer.org.
Please return COMPLETED form to:
TENANTFORM@FAIRFAXWATER.ORG
Fax: (703)466-6863
Phone: (703)698-5800
The following information must be
completed in full and signed by the legally recorded property owner
or authorized agent to establish new service. *If this form is altered it will not be accepted and will cause
delays with processing and your tenant starting service. Please allow us at least 4 hours, after submission,
on a business day, to process your form. Once the tenant receives notification that the form has been
approved, the tenant MUST call our Customer Service department to establish service during our normal
business hours Monday-Friday between 8:00am and 4:30pm and for further instruction on how to make
the Lien Offset payment.
All tenants are required to pay $190
(Lien Offset payment) prior to the service start date. This payment
will be applied to the final bill once the tenant has notified Fairfax Water to disconnect service.
enter as MM/DD/YYYY
enter as MM/DD/YYYY
