THIS FORM IS NOT FOR LANDLORD USE To stop service for a tenant, please email us at customerservice@frederickwater.com Service Street Address (required) Service City (required) Service State (required) Service Zip Code Date to Stop Service* Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033 *Stop Service Date must be Monday through Thursday for owners and Monday through Friday for renters, invalid dates will be changed to the next available date Reason for Stop Service (required) Sold Rental Foreclosed Status (required) Landlord Owner Renter Property Manager Contractor Realtor Name (required) Email Address (required) Telephone Number (required) Forwarding Address (required) Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Signature FOR OWNERS: I UNDERSTAND THAT THE METER WILL BE TURNED OFF AND THE ACCOUNT PUT INTO OCCUPANT STATUS. A START SERVICE APPLICATION MUST BE COMPLETED AND A $40.00 APPLICATION FEE PAID BEFORE SERVICE IS RESTORED. FOR TENANTS: I UNDERSTAND THAT THE METER WILL NOT BE TURNED OFF AND WILL REVERT BACK INTO THE OWNER’S NAME AS OF THE STOP SERVICE DATE. ANY CHANGES TO THE STOP DATE MUST BE SUBMITTED IN WRITING. IF METER IS TURNED OFF A $75.00 FEE WILL BE CHARGED FOR SAME DAY TURN ON. Leave this field blank