Closing Account Application Request for Closure of Account Date of Request* MM slash DD slash YYYY Date Escrow Closed* MM slash DD slash YYYY Date to Turn Water Off MM slash DD slash YYYY Escrow # Title Company Title Company PhoneAccount Number* Service Address* Required InformationRequested by Owner Tenant Name* First Last Forwarding Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Ext: CertificationBy signing this form, I am requesting that Citrus Heights Water (CHWD) discontinue water service to the above mentioned service address and close my account. I am also acknowledging the following: Upon receipt of the application, CHWD will obtain a final meter reading at this service location. If CHWD finds the property to be occupied, WATER SERVICE WILL NOT BE TERMINATED. You may continue to be billed for the water service. CHWD will prepare a final bill and mail a Final Meter Statement to my forwarding address noted above. CHWD will apply any credits that I have on this account to this final bill. If the Final Statement has a credit balance or there is a deposit on this account, CHWD will mail a refund check within 30 days. If there is a balance due on the Final Meter Statement, the entire balance is due and payable upon receipt and delinquent after 20 days from the date on the statement. CHWD has the right to proceed with further collections, if full payment is not received by the due date. These procedures may include, but are not limited to, assessing late penalties and securing the services of a collection agency to recover the outstanding balance and associated fees. There are risks to locking off the service(s) prior to the transfer of ownership including, but not limited to, the loss of landscaping, damage to water heater or solar water heating systems, lack of water for sanitation purposes or damage to pool equipment. I certify that I understand and agree with the above statements regarding termination of my water service and that Citrus Heights Water District cannot be held responsible for any damage done at this service address as a result of locking off the service(s).Owner's Signature* Date MM slash DD slash YYYY Δ SIGN UP FOR ONLINE BILL PAY TODAY! GO PAPERLESS NOW
