Today’s Date	[…]
Account Number	[…]
Requested Date of Disconnect	[…]
☐	Account Closure	☐	Temporary Disconnect
☐	Commercial	☐	Residential
☐	Owner/Landlord	☐	Rent/Lease

PLEASE CHECK ALL THAT APPLY

[…]

SERVICE ADDRESS:

By completing this form, you acknowledge that:

The water service to the relevant property will be disconnected on the date requested above.

The disconnection of water services does not constitute a release of liability for payment of the final bill.

Any final charges are due within 30 days of receipt.

For water service to be reconnected you must complete and submit the required document(s) and pay the required reconnect fee.

CUSTOMER INFORMATION

[…]

Customer Name:

[…]

Billing Address (Street/PO Box):

[…]

[…]
[…]
City	State	Zip Code

[…]

Phone Number:

OWNER INFORMATION

[…]

Owner Name:

[…]

Owner Address (Street/PO Box):

[…]

[…]
[…]
City	State	Zip Code

[…]

Phone Number:

[..]	[..]

Signature
Printed Name
Date
For Office Use Only
Date received:	[..]	Received by (initials):	[.]
Date entered into billing system:	[..]	Entered by (initials):	[..]
Date sent to field:	[..]	Sent by (initials):	[..]
Date disconnected:	[.]	Disconnected by (initials):	[..]