If you are currently on a temporary discontinuance and would like to move your re-establishment date to an earlier time, please fill out the form below.

Account Number (located on your water bill)

Account Number (located on your water bill)

Name

 *

Name

Address in Queen Creek

 *

Address in Queen Creek

Phone Number

 *

Phone Numberext.

E-mail Address

 *

E-mail Address

Requested Date of Re-establishment

 *

Requested Date of Re-establishment

I read and agree to all the above information.

 *

Yes

Electronic Signature (your name in this box serves as a signature)

 *

Electronic Signature (your name in this box serves as a signature)

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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