Request for Discontinuance of Electric Service

Existing Account

Section 1: Existing Account

Today's Date

Name of Account

Re-order	First Name	Middle Name	Last Name	Weight	Operations
	First Name	Middle Name	Last Name	Item weight

more items

Enter First, Middle, Last

Phone Number

Phone Number
	Phone Number	Item weight

more items

Account Number

member_email

Physical Address on Account

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Section 2: Disconnect Request

Are you disconnecting because you are selling?

Yes

New Owner / Realtor

Owner

Realtor

New Owner / Realtor Name

New Owner / Realtor Phone

For all phone numbers, please use the format, XXX-XXX-XXXX.

Is this a rental unit?

Yes

Owner's Name

Owner's Phone Number

For all phone numbers, please use the format, XXX-XXX-XXXX.

Owner's Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Address for Final Bill

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Confirmation

I (We) hereby request the electrical service provided to the address listed above by San Miguel Power Association be disconneted. I (We) understand and agree that I (We) are responsible for electrical usage and the bill thereon until the date of the final meter reading and actual disconnect. This agreement becomes effective the date it is signed. By signing below, I (We) certify that I am (We are) authorized to enter into this agreement and agree to hold harmless and indemnify San Miguel Power Association for any damages whatsoever as a result of this agreement. In case of default, I (We) agree to pay court cost, reasonable attorney's fee, and all collection costs.

Request Date for Disconnect

Authorized Signature

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