H2GO Brunswick Regional Water & Sewer

DISCONNECT REQUEST

Account holders may complete this form to arrange disconnection of services. Final readings will be taken on metered services within five business days of the termination effective date. Completed disconnect forms can be printed and faxed to 910-371-6441 or mailed to Brunswick Regional Water & Sewer, H2GO P.O. Box 2230 Leland, NC 28451. A final bill will be mailed to account holder with the words “FINAL BILL”. Only bills marked “FINAL” terminate account holder’s financial responsibility for service.

Account Number:

Account Holder's First Name:

Middle Name:

Account Holder's Last Name:

Service Address:

City:

State:

Zip:

Effective Date for Termination Request:

* Final readings are obtained within five business days from the effective date.

Final Billing Address:

City:

State:

Zip:

Telephone:

Home Telephone:

Work Telephone:

Email:

*A Customer Service Representative may contact you if additional information is needed.

Account Electronic Signature:

Date:

I understand that my final bill will come from my security deposit and if that bill exceeds the security deposit I will be responsible for the balance owed.