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2. 
3. Kaufman County, Texas

   Development Services: 9-1-1 Utilities Application

5. 911 Utilities Address
7. Date of Request*
   Date of Request
9. Applicant Personal Name*
10. Applicant Business Name*
12. Applicant Email Address*
13. Applicant Phone Number*
15. Applicant Mailing Address*
17. City*
18. Zip Code*
22. Property Identification

    Please provide any information that might assist in locating your property. The location of the proposed driveway and existing addresses adjacent to the property are necessary for assigning an address in the correct sequence.

24. Property ID # (from County Appraisal District):
26. Subdivision Name
27. Subdivision Phase
28. Subdivision Lot
30. Nearest Intersection
34. Reason For Address*
    -- Select One --ElectricWaterInternetSignageOther
36. Explain Description of Equipment*
38. Site Plan*
40. Additional Documentation
42. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
44. Electronic Signature*
45. Date Signed*
    Date Signed

47. If you check the box: Receive an email copy of this form. You’ll receive an e-mail from NoReplyCivicPlus.com.

Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field