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2. Water & Sewer - Customer Termination of Service Request

4. Account Number
5. Stop Service Date
   Stop Service Date
9. Customer Name
11. Service Address
12. Zip Code
14. FORWARDING ADDRESS:*
16. Address2
18. City
19. State
20. Zip
22. Phone Number
24. Email Address

26. Any deposit held by the County of Rockingham Public Works when a customer terminates service will be applied to the final bill.  Any amounts remaining will be refunded by a County check mailed to the forwarding address supplied by the customer when notice of termination was given.

28. Acknowledgement*

    1. I acknowledge the information given above is true and correct to the best of my knowledge.
29. Date*
    Date
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field