Graysville Request to Final

CITY OF GRAYSVILLE

246 SOUTH MAIN STREET P.O. Box 130 GRAYSVILLE, ALABAMA 35073 TELEPHONE: (205) 674-5643 FAX: (205) 674-5640
REQUEST TO FINAL SERVICE
Termination Date*

MonthDayYear
Date
Choose one or both*

GasWater
Account Name*
Please sign as account owner, power of attorney, or executor to final service. All documents must be presented to show person signing is legal authority of the account. Please provide copy of license and/or person who has authority on behalf of account owner.

By signing this agreement, we agree to hold Graysville Gas and Water harmless from any adverse action resulting from the termination of utility service(s GRAYSVILLE GAS AND WATER DOES COLLECT UNPAID BALANCES THROUGH MULTIPLE COLLECTION ACENGIES!
Drivers Licenses Number#: & (Provide Copy)*
Please provide Drivers License Copy and Power of Attorney or Executorship documentation if applicable:*

Cancelof
Service Address*
Customer/Account #*
Phone Number Cell or Home*
Forwarding address to send final bill or refund to:*
DUE TO DELIVERY ISSUES, WE GIVE THE OPTION TO PICK UP REFUNDS.
Pick up*

YesNo
Authorized Signature/Printed Name*

Clear
Date*

MonthDayYear
Date
Email
example@example.com
Should be Empty: