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FORMS

Application for Termination of Water/Sewer Service

DOUGLASVILLE-DOUGLAS COUNTY WATER AND SEWER AUTHORITY

TERMINATION OF WATER/SEWER SERVICE

Customer Name

Date of Birth

Last 4 Digits of SSN

Driving License No.

Phone Number

Alternate Phone number

Email Address

Customer is:

Date Requested for Service Disconnection

Service Address to be Disconnected

Address Line 1

Address Line 2

City

State

Zip Code

Forwarding Address

Address Line 1

Address Line 2

City

State

Zip Code

Today's SSN No.

Signature

Clear Signature

Today's Date