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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. 1. I, the undersigned customer, hereby request that my water assigned to the above noted account and address to be disconnected from JCSUD 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 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 final bill. If there is any credit due to you, a check will be mailed to the forwarding address provided.
    2. 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
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field