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2. Disconnection of Water Service Request Form

   Please note: If the form is submitted after noon, same-day service is not guaranteed.

4. Today's Date*
   Today's Date
6. Name service is currently in*
8. Service Address*
10. Last four digits of SSN#*
12. Last four digits of Driver's License #*
14. Forwarding Address
16. Address Line 1*
17. City*
19. State*
20. Zip*
22. Date to be disconnected*
    Date to be disconnected
24. First Name
25. Last Name
27. Email Address
29. Phone Number*
31. Digital Signature
33. DISCLAIMER

    ***PLEASE NOTE THERE WILL BE A FINAL BILL. THIS ACCOUNT IS SUBJECT TO COLLECTIONS IF THE FINAL BILL ISN'T PAID IN A TIMELY MANNER. ***

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field