Request to Terminate or Relocate Water

Service & Request a Refund of

Deposit/Membership
Todays date: ______________________________________________________________________
Your New Light Water Association, Inc.

Account Number:

_________________________________

Name on account: __________________________________________________________________

Address: __________________________________________________________________________
City: ________________________________________ State: ________ Zip Code ________________
Billing Address: ____________________________________________________________________
City: ________________________________________ State: ________ Zip Code ________________
Date you want water service terminated at above address:

________________________________

Are you moving to a different residence served by New Light Water Association?

____ Yes, ____No

New Address for service:

Name on account: __________________________________________________________________
Address: __________________________________________________________________________
City: ________________________________________ State: ________ Zip Code ________________
I will no longer be served by New Light Water Association, Inc. and would like the deposit check
returned to the address below. (You can expect a check for the balance of the deposit minus
the balance of last bill approximately 30 days after the next billing cycle is completed):
Name:

___________________________________________________________________________

Address: __________________________________________________________________________
City: ________________________________________ State: ________ Zip Code ________________
Telephone number ____________________________
Signature:

________________________________________________________________________