3. 
   

5. Sold My Property

7. Today's Date*
   Today's Date
9. Account Number
10. Account Name*
12. Service Address*
14. Phone Number*
15. Email Address*
17. Closing Date*
    Closing Date
    Note: The seller is responsible for all charges through the day of the closing.
18. Disconnection Date*
    Disconnection Date
    Please give the buyer at least 24 business hours to initiate service.
19. Upload Closing Statement
    If the closing has already occurred, please provide a copy of the signed closing paperwork.
21. Did you stay in the property after the closing date?*

    1. Yes
    2. No
22. Comments

    If you stayed in the property after the closing date, please provide date you vacated the property.

24. Forwarding Address*
26. City*
27. State*
28. Zip Code*
30. New Owner's Name
32. I AM AWARE THAT THERE IS A $10.00 SERVICE CHARGE TO THE SELLER FOR DISCONNECTION OF SERVICE. THE BUYER WILL NEED TO PROVIDE A COPY OF THE HUD, PHOTO I.D., $15 APPLICATION FEE, AND A DEPOSIT BASED ON THE METER SIZE.
34. 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.
36. Electronic Signature
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field