Change of Service Acknowledgement

Customer's name*

Complete address where alarm system is located*

Customer's E-Mail address (they will receive a copy of this form)*

example@example.com

Name of their previous alarm company*

Amount rep agrees to rebate customer if any to offset balance*

ACKNOWLEDGEMENT STATEMENT

I have chosen to change my alarm services from (_____________________________) “current alarm company” to ADT through Carolina Smart Home. Neither BFD Carolina (DBA/Carolina Smart Home) nor ADT have any affiliation with them, in fact they compete with them. This is a new install not part of an upgrade with my current alarm company and no negative representation was made by the sales representative nor any other Carolina Smart Home agent regarding them in order to influence my choice to change my services to Carolina Smart Home/ADT. Furthermore, I confirm that any and all information regarding the terms of my existing agreement was based on information voluntarily provided by me.

If a balance exists, the Carolina Smart Home representative has agreed to rebate me $__________ to pay down or offset the amount due. Any overage above this amount is solely my responsibility. Neither Carolina Smart Home, ADT nor the sales representative can be held responsible for any additional amount at a later date. It is solely my decision as to how I handle any payments and balances if any with my current company.

Customers Signature*

Date*

Date

I signed this form on the date listed herein and consented to electronic signature method. A copy was emailed to me.

CHANGE OF SERVICE ACKNOWLEDGMENT FORM