Request for Service Discontinuance

Request for Service Discontinuance
Customer Details:
Full Name*

First NameLast Name
Subdivision*
Account Number*
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Discontinue Date*

MonthDayYear
Date
Must be a future date and not a weekend or holiday. Form must be submitted 24 hours before requested date.
Email Address*
example@example.com
Forwarding Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, the undersigned customer, hereby request that my water assigned to the above noted account and address to be disconnected from Mustang SUD (the "District") service and that my deposit be refunded to me if not done previously. If I should ever want my service reinstated at this address, I acknowledge that I may have to reapply for service as a new member and pay all fees required by the District's Rate Order in effect at the time. I understand that the District ability to provide service in the future will be dependent upon system capacity, which may be limited, and that capital improvements will be constructed at my cost. I further represent to the District that my spouse joins me in this request and I am authorized to execute this request for service discontinuation on behalf of my spouse. If your account has a deposit, it will automatically be applied to your next bill. It can take up to 45 days for final billing. If there is any credit due to you, a check will be mailed to the forwarding address provided. Check processing times may vary.
Electronic Signature Agreement*

I agree.
Signature*

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: