Form Center

2. Request to Stop Services
4. Request Type*
   -- Select One --Stop Services
5. Water Account Number*
6. Stop Services Date*
   Stop Services Date
8. First Name*
9. Middle Initial
10. Last Name*
11. Suffix
13. Phone Number*
14. Type of Phone Number:*
    -- Select One --CellHomeWork
15. Email Address*
17. Service Location Address*
18. Suite or Apt#
20. Date of Birth:*
    Date of Birth:
21. Last 4 of SSN*
23. Forwarding Mailing Address*

    This is where your final bill and/or refund check will be mailed.

24. Suite or Apt#
26. City*
27. State*
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
28. Zip Code*
30. Please read and agree to the following statements before electronically signing your request
32. • If there is a deposit associated with this location, it will be applied to the final bill. If after the deposit is applied to the final bill, if the remaining deposit credit is greater than $5 after your debts to the City are satisfied, the City will mail a check to you at the forwarding address provided. If the remaining deposit credit is less than $5, you authorize such amounts to be contributed to the water hardship fund, unless you submit a written request to the City at 1600 Mist Lake Drive, Durham, NC 27704 stating otherwise.
    • Please note that if you do not pay all charges due the City, the City may take collection action against you including, but not limited to, use of a collection agency and the North Carolina Department of Revenue Debt Set-Off Program. Also understand that you may not open up an additional utility account with the City until all charges from prior accounts for which you are responsible are paid.
    • The information that you have provided on this application is correct to the best of your knowledge.
34. Notice regarding electronic signature

    Pursuant to the North Carolina Uniform Electronic Transactions Act, digital application documents are legally binding in the same manner as are hard copy documents executed by hand signature. The applicant hereby consents to the use of electronic or digitized signatures or scanned copies of original signatures, and the applicant intends to be bound by the application and any related documents.

    By submitting an application with an electronic or digitized signature or a scanned copy of the original application, you acknowledge, agree, and authorize your electronic or digitized signature or your scanned original signature to be valid and binding upon you in the same manner as are hard copy documents executed by hand signature.

39. "Sign" your application by typing your name below:*
40. Date:*
    Date:
Leave This Blank:


42. Submit

* indicates a required field