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2. I am requested services to be terminated on the following date (weekdays only):*
   I am requested services to be terminated on the following date (weekdays only):
4. Account Number
6. First and Last Name*
8. Service Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Email Address
17. Mailing Address for Final Bill*
19. City*
20. State*
21. Zip Code*
25. Deposit Refund Options*
    -- Select One --I did not pay a depositI will use my deposit to pay the balance on my account. Any deposit remaining will be mailed to meI will pay the balance in full and receive my deposit refund in fullI will pay part of the balance on my account and use my deposit for the remaining balance
29. Termination Agreement
    The account holder is responsible for all metered consumption until a final meter reading is taken. The actual date of the final meter reading may not be the exact date requested but will be within 72 hours of the date requested. The preference as to how any deposit is used is only given as a courtesy. The Town reserves the right to use your deposit to pay any balance on your account if it becomes delinquent at any time. Please allow 60 days for the Town to process and return your deposit.
31. By typing my name below I hereby agree to the above termination agreement*
32. Date*
    Date
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

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