Town of Culpeper
400 South Main Street, Suite 109
Culpeper, VA 22701
Phone: (540) 829-8220
Fax: (540) 829-8239
UTILITY DEPOSIT REFUND RELEASE
Date Requested to be Released: __________________________________________
Account Number: ________________________________________________
Service Address: ________________________________________________
Amount of Deposit on Account: ____________________________________
Balance Due on Account: __________________________________________
Verified By: ______________________________ Date:_____________
Customer Service Representative
I, ____________________________________ hereby request that my name be
removed from the above referenced utility account. I am releasing my rights to any
deposit that was placed or any applicable refunds/overpayments that may occur on
this account. I am aware that in order for me to be released from the service
address above, the balance owed on the account must be ZERO and the account
must be closed out. The remaining individuals on the account and the utility deposit
amount will be transferred to a new account.
_____________________________ ______________________________________
Print Name Signature Date
Co-Applicants on Account:
_____________________________ ______________________________________
Print Name Signature Date
_____________________________ ______________________________________
Print Name Signature Date
_____________________________ ______________________________________
Print Name Signature Date
SUBSCRIBED, ACKNOWLEDGED, AND AFFIRMED BEFORE ME THIS_________ DAY OF
_______________, 20________. MY COMMISSION EXPIRES:____________________
_____________________________________________
NOTARY
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