Water/Sewer Termination

Service Address To Be Terminated

Address

Unit #/P.O. Box

City/Town

State/Province

ZIP/Postal Code

Country

Account Number

Date of Termination

First Name

Last Name

Customer Identification

I am the owner of the service address.

I am the tenant of the service address.

Landlord Name

New Property Owner Name

Customer Forwarding Information

Please provide us with your new address information.

Address

Unit #/P.O. Box

City/Town

State/Province

ZIP/Postal Code

Country

E-Mail Address

Telephone

I hereby request the Town of Essex - Water Department to terminate water service to the premises at the above address. I hereby further agree to pay for service at the authorized rates to the date on which the service is terminated. Final statements are payable to E.L.K. Energy Inc. on or before the due date. All accounts not paid by the due date are subject to a late payment charge, as well as collection action including disconnection and payment of a reconnection fee.

Signature

Sign above

Date