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Service Disconnection Form
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**Payment for current balance due at time of Service Disconnection**
Date of Birth
I understand that
there will be a final bill for service for base rates and usage through the disconnection date.
I understand that
if I have not already received my deposit as an account credit, my deposit will be applied to the final bill and any past-due balance.
I will be refunded any remaining amount of the deposit, which will be mailed to the forwarding address I have provided above.
***All delinquent accounts will be sent to McCreary, Veselka, Bragg & Allen, P.C. Attorneys at Law.
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.
I agree to the above statement and confirm that all the information on this application is true and accurate to the best of my knowledge.
Signature: First M. Last
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