Request for Service to be Cancelled

1

Street Number

 *

2

Street Name

 *

3

City

 *

4

State

 *

(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

5

ZIP

 *

6

Daytime Contact Number

 *

Forwarding Address (if different than service address)

7

C/O or Attention

8

Address

9

City

10

State

(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

11

ZIP

Verify Name On Account To Cancel Service

12

First Name

 *

13

Last Name

 *

14

Birth Date

 *

15

Social Security Number (last 4 digits)

 *

16

Driver's License Number

 *

17

Driver's License State

 *

(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

18

Date For Service To Be Cancelled

 Please DO NOT enter a Saturday, Sunday, or holiday date.

 *

Please review your application form carefully. Make any corrections necessary, then click on the 'Submit' button. Please wait for your confirmation to appear. Thank You.

Note: The confirmation message only indicates that your request has been received. It does not confirm that your service request can be completed.

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