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2. Account Information
4. Name on Account *
5. Account Number*
6. Date for Account to be finalized *
   Date for Account to be finalized
8. Service Address*
   Address, City, State, Zip
9. My Account has been set - up for ACH/Automatic Bank Draft*

   1. yes
   2. no
13. Send My Final Bill To:
15. Mailing Address*
    Address, City, State, Zip
16. Phone:*
18. Acknowledgement and Signature
    I am requesting that my Water/Wastewater account be finalized. I understand that I am responsible for the cost of water/wastewater service up to the date the account is finalized. I understand that my auto-payment from my Checking/Savings account will be cancelled with this request , and I understand I will be responsible for paying the final bill manually. The Utilities Department will endeavor to act upon telephone , e-mail, or verbal orders to discontinue service, but in the event of a dispute, only a signed written notice will be considered proof of notification. If I do not pay my account in full I understand that any final balances can be transferred to a current account and is due immediately or that my past due finalized amount will be sent to a collection agency.
20. Signature *
21. Date:*
    Date:
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23. Submit Submit and Print

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