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Water and Wastewater – Cancellation Request

Account Number:

Effective/Closing Date (MM/DD/YYYY):

Address of Municipality of Port Hope Water and Wastewater Account:

Name on Account (Primary):

Name on Account (Secondary):

Forwarding Address For Final Bill - Including Postal Code:

Email Address:

Phone Number:

Please Note:

i) If on a Pre-Authorized Payment Plan you will be required to pay the final bill manually. Please ensure you complete our water and wastewater cancellation of pre-authorized payment plan form to cancel your pre-authorized payment plan.

ii) If you are moving within the Municipality of Port Hope your account number will change. If you pay your water bill through your financial institution, please update your account number once you receive your first bill.

I, the undersigned, hereby certify that the information above is true and correct. Please sign below:

Clear

Date:

Personal Information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990 c. M56, as amended. Inquiries about the collection of personal information should be directed to the Municipal Clerk.

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Water and Wastewater – Cancellation Request

Please Note: