TERMINATE SERVICE

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Account No. to Terminate Water Service

Service Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Effective Date

YYYY

Name

First Name

Last Name

Primary Phone Number

(###)

###

####

Work or Cell Number

(###)

###

####

Billing or Forwarding Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you own or rent?

Own

Rent

Landlord's Name

Landlord's Phone

Landlord's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Comments/Questions

Permission

By initialing this box, I affirm that this information is true and I am authorized to TERMINATE WATER SERVICE at this address.

Today's Date

YYYY