Disconnect Service

2. First Name*
3. Last Name*
5. Account Number*
7. Service Address*
9. City*
10. State*
11. Zip Code*
13. Discontinue Date*
    Discontinue Date

    Must be a future date and not a weekend or holiday.

14. Email Address*
16. Forward Address*
18. City*
19. State*
20. Zip Code*

22. I, the undersigned Account Holder, hereby request that my water assigned to the above-noted account and service address be disconnected from Johnson County Special Utility District (JCSUD) service(s).  If I should ever want/need my service reinstated at the above service address, I acknowledge that I may have to reapply for service and pay all fees required by the district's rate order in effect at the time.  I understand that the district's ability to provide service in the future will depend upon system capacity, which may be limited, and that capital improvements will be constructed at my cost.  I further represent to the district that the Co-Applicant/Spouse joins me in this request, and I am authorized to execute this request for service discontinuation on behalf of the Co-Applicant/Spouse.

    I further understand that if my deposit has not been previously refunded, the deposit will automatically be applied to the final bill.  If any credit is due to me, a check will be mailed to the forwarding address provided.

    Electronic Signature Agreement*

    By signing 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.

    
    
    

    
    

24. Electronic Signature*
25. Date*
    Date
Leave This Blank:


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

    This field is not part of the form submission.

29. Submit

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