Request For Service Discontinuance CROSS TIMBERS WATER SUPPLY CORPORATION 2032 East Hickory Hill Road Argyle, Texas 76226 (940) 584-0780 Fax: (940) 584-0781 www.crosstimberswater.com RENTER'S REQUEST FOR SERVICE DISCONTINUANCE I,Namehereby request that my water meter (serial #)Input Serial#Account #Input Account #located at Input locationbe disconnected from Cross Timbers Water Supply Corporation service. I understand that if I should ever want my service reinstated, I may have to reapply for service as a new Member, and I may have to pay all costs as indicated in a then current copy of the Cross Timbers Water Supply Corporation Tariff. Future ability to provide service will be dependent upon system capacity, which I understand may be limited and may require capital improvements to deliver adequate service. I also understand that these improvements will be at my cost. I further represent to the Corporation that my spouse joins me in this request, and I am authorized to execute this Request for Service Discontinuance on behalf of my spouse. I request that Cross Timbers Water Supply Corporation send my final bill to the following address:Name: First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner Account#OwnerSignatureDate Effective DateEffective Date: New MemberNew MemberNOTE: Charges for service will terminate when this signed statement is received by the Cross Timbers Water Supply Corporation office.