Service Address To Be Terminated Service Address Address Unit #/P.O. Box City/Town State/Province - Select ---- Canada Provinces ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon--- US Provinces ---AlabamaAlaskaAmerican SamoaArizona ArkansasArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)CaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Country - None -CanadaUnited States Account Number Date of Termination Name 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. Customer Forwarding Information Address Unit #/P.O. Box City/Town State/Province - Select ---- Canada Provinces ---AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon--- US Provinces ---AlabamaAlaskaAmerican SamoaArizona ArkansasArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)CaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Country - None -CanadaUnited States 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