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Cancellation of Automatic Water Bill Payment Agreement

2. Request to Cancel Water Bill Automatic Bill Payment Agreement
   This is a request to cancel the previously set up automatic payment of your water bill for any reason. We must receive your request for cancellation at least 10 business days prior to the due date to discontinue automatic withdrawals. All information provided in this form is subject to Freedom of Information Act requests subject to State law.
3. 
5. Desired Effective Date*
   Desired Effective Date
7. First and Last Name*
8. Water Account Number*
10. Service Street Address*
11. Zip Code*
13. Phone Number
14. Email Address
18. Mailing Street Address (If Different)
19. Mailing City, State, Zip Code
21. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Electronic Signature*
24. Date*
    Date
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field