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 Year2002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032 *Stop Service Date must be a week day (Monday through Friday), selected weekend dates will be changed to next available business day 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 Year191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 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 $30.00 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