2. ---
4. Customer - Account Information

6. ---
8. Name*
10. Customer Number - Account Number*
12. Service Address*
14. Phone Number*

16. ---
18. Agreement

20. ---
22. Please remove the Customer-Account number listed above from the Auto Draft program.
    
    I understand this will be effective on my next statement and any current amount owed on the account will still draft on the designated date for the designated amount.
    
    Type I AGREE in the authorization box below if you agree with the terms stated above.
24. Authorization*
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field