APPLICATION TO DISCONTINUE SERVICE Complete and return this form with all required documents and information to: Scott County PSA 156 Legion Street Weber City, VA 24290 276-386-3401	OFFICE USE ONLY Received: _____/_____/20_____ Water Sewer Account No. _______________ Meter No. _________________ Fulfilled 10-yr User Agreement: Yes No No agreement Disconnected: ____/____/20____ Meter: locked removed ACH list: removed N.A. Form scanned into system Staff initials: ________

Please mark the appropriate boxes and fill in the required blanks:

Account number:	Enter your SCPSA account number
Discontinue:	☐ Water	☐ Sewer
Reason:	☐ Moving	☐ Customer deceased	☐ Have other water supply	☐ Other
Name on account:	Enter first name	Enter middle name	Enter last name
Service address:	Enter street address or PO Box	Enter city	Enter state	Enter zip code
Required security information for account holder:	Enter date of birth MM/DD/YEAR	Enter social security number
Driver’s license:	Enter state that issued license	Enter driver’s license number
If not the account holder, I am the:	☐ Executor of estate, and ☐ Certificate of Qualification is attached	☐ Person in charge of the account, and ☐ Proof I am & that account holder is unavailable is attached.
If not the account holder:	☐ Show photo ID when deliver application	☐ Attach copy of photo ID if mailing
Do you pay bill by bank draft?	☐ Yes, I pay using automatic bank draft (ACH)	☐ No, I pay using other methods
Final bill address:	Enter street address or PO Box Enter city Enter state Enter zip code
Telephone Nos.:	Enter primary phone number	Enter secondary phone number

I hereby request that service be discontinued as described and certify that the above information is correct.

Printed Name: ________________________________________________________

Signature: ____________________________________________________________________ Date: ____/____/20____

SCPSA will disconnect the service within 5 business days after the date the SCPSA office receives this application.