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Contact Information

Termination Date:*
Termination Date:
Service Address*
i.e. 1030 Main St. S.W.
Name*
Email Address
Mailing Address
if mailing address is different than above service address
Phone Number*
Cancel Pre-Authorized Payment
1. Yes
2. No
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Deposit Refund

Request for Utility Deposit Refund
The refund of a utility deposit is subject to the customer making a request in writing and the customer meeting all the requirements of the Town of Slave Lake By law #07-2009. As per Section 10 (3): a deposit paid under Section 8 will be refunded only upon the consumer’s request and at the discretion of the Chief Administrative Officer. As per Section 10 (4): if refundable pursuant to this Section, or upon termination of the supply of utility services, a deposit shall be returned to a consumer together with interest as provided in Section 9, after deducting there from all outstanding charges for the supply of utility services, including the cost of shutting off or discontinuing any utility service for non-payment of utility accounts.
Name*
As appears on utility account
Forwarding Mail Address*
Please provide your forwarding mailing address
City
Prov.
Postal Code
Phone Number*
Account Number
insert your current account number
I hereby request the Town of Slave Lake to review my account to see if it qualifies for a deposit refund. If refund request is denied the Town of Slave Lake will contact me. If approved, I request the refund of my deposit to be returned as follows:*
1. Apply deposit to account
2. Issue a refund cheque
3. Transfer Service to new account
4. Issue a refund by direct deposit
If you have selected Transfer Service to New Account please state your new service address. Please note that your new service address must be within the Town of Slave Lake.
If you selected a refund by direct deposit, please state and email address for a notice of deposit and attach an image of a void cheque below
Please attach an image of a void cheque if you selected a direct deposit refund.
Final Read
Please provide a final read on the day you have notified the Town of Slave Lake that you will be vacating the premises. That can be done by taking a picture of your water meter with the final read and emailing/texting it to utilities@slavelake.ca, be sure to include your utility account number or service address.
Failure to submit final read can result in being estimated 10-25 m3 on your final utility invoice.
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Signature

Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*
The personal information requested on this form is being collected by Municipal Operation as required by the Town of Slave Lake, under the authority of the Freedom of Information and Protection of Privacy Act (FOIP act) Section 33(c). If you have any questions about the collection or use of your personal information, contact the Town of Slave Lake FOIP coordinator at 780-849-8000.

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

This field is not part of the form submission.
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Request to Terminate Utility Service

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Slave Lake Alberta, Canada

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