City of Escalon
Cancel Utility Services Form
Stop Property Address: Customer Account #:
Customer Information
Name: DOB DL# SSN
NEW Mailing Address:
Cell Phone # Home Phone # Other #
Employer Name & Address:
Spouse/Partner: DOB DL#
SSN Cell Phone #
Email Address:
To Terminate service, you must provide current contact information so that we can contact you in the event we cannot terminate service based on the information provided or to return a deposit.
Are you a Renter or an Owner
If you are a renter: Move out date: (Date keys are returned to the landlord)
Landlord's Name:
Landlord's Phone #:
If you are the owner: Close of Escrow Date: or Short Sale/Foreclosure Date:
Deposit Information
If you have a deposit on your account, it will be applied to the final bill and any remainder over $5.00 will be refunded to the account holder. Deposit refunds are processed two to four weeks after the termination of service and are mailed to the account holder. If you are simultaneously starting service elsewhere in Escalon, your deposit will be transferred to your new account.
Date: Type Name Here:
By typing your name you agree to the following:
By typing in your legal name, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. By typing in your legal name you consent to be legally bound by this form's terms and conditions. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide the City of Escalon, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and the City of Escalon. You also represent that you are authorized to sign this form for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this form.
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