Disconnection or Lock Request

Etowah Water and Sewer Authority require this authorization form to be completed to prevent the unauthorized use of your water account.

Complete the form below and submit.
Water Account Number*
Name on Account*
Service Address*
Please Read Carefully
- Lock Request: Please lock the above mentioned account. As the owner of the account, I understand there will be a $75.00 reconnect fee to reinstate the service. A deposit is required to transfer to the new renter’s name. I also understand that I will be responsible for the monthly minimum billing until the account is transferred or until I make a request to have the service taken out of my name.
- Disconnection Request: Please disconnect the above mentioned service and void my contract. I understand once my water meter is locked my contract with Etowah Water and Sewer Authority will be voided and my deposit will be applied. If I should want my service back, there will be a $75.00 reconnect fee, and a new deposit will be required.
Name*
First Last
Contact Phone Number*
Date*
MM slash DD slash YYYY
Signature*
Phone
This field is for validation purposes and should be left unchanged.

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