Office Use Only

'339711A4-D8C5-437D-A33A-E312CB4E0FBD.jpeg' attached Date Completed:

Disconnect Service Form

In order to complete your request, we will require
a copy of your valid picture ID.
Para completer su solicitud, necesitaremos una copia de su identificacion con
foto valida

We do not disconnect the same day, weekends or holidays/ Nosotros no

desconectamos el mismo dia, fin de semana o dia festivos.

Daniel Torrez
Account Name (Nombre de la cuenta): ______________________

3014260
Account Number (Numero de la cuenta): _______________________

0427
Last 4 of Social Security (Ultimos 4 de su Seguro Social): _______

Address to be disconnected (Direccion para desconectar):

1729 Fieldcrest Cir, Rock Hill, SC 29732
________________________________________________________

Date for disconnection (Fecha de desconexion): ___/___/____

05/28/2023

Forwarding Mailing Address (Direccion de reenvio):

3504 Burner Dr, Charlotte, NC 28205
____________________________________________________
9739316482
Phone Number (Numero de Telefono): _____________________

D.torrez@outlook.com
Email Address (Correo Electronico): _______________________

05/15/2023
Signature: __________________________ Date: _______________
 REFERENCE NUMBER
C28E4D1D-C44F-4A4C-A1A5-EF8D914BC6AB

SIGNATURE CERTIFICATE

TRANSACTION DETAILS DOCUMENT DETAILS

Reference Number Document Name

C28E4D1D-C44F-4A4C-A1A5-EF8D914BC6AB Disconnect Service Form
Transaction Type Filename
Template Signer Link disconnection_2021.docx
Sent At Pages
05/15/2023 11:46 EDT 1 page
Executed At Content Type
05/15/2023 11:51 EDT application/vnd.openxmlformats-officedocument.wordprocessingml.document
Identity Method File Size
none 41 KB
Distribution Method Original Checksum
manual 1b9aaadd5eb2dc53aa4587f47f361df445e54d953ce0355d529d2c2b8fa51cef

Signed Checksum
6e74711437430efda1b5a7fcd1152ebee7101dbdf49009a526a4fa4f000a982b

Signer Sequencing
Disabled
Document Passcode
Disabled

SIGNERS
SIGNER E-SIGNATURE EVENTS

Name Status Viewed At

Daniel Torrez signed 05/15/2023 11:46 EDT
Email Multi-factor Digital Fingerprint Checksum Identity Authenticated At
d.torrez@putlook.com 8da5ae850cf544c7276970699999d24a0a6652799a1a2a418f0244843f0317e7 N/A
Components Signed At
IP Address
11 05/15/2023 11:51 EDT
172.58.251.86
Device
Mobile Safari via iOS
Drawn Signature

Signature Reference ID
D7533CD7
Signature Biometric Count
16

AUDITS
TIMESTAMP AUDIT

05/15/2023 11:46 EDT Signer viewed the document on Mobile Safari via iOS from 172.58.251.86.

05/15/2023 11:51 EDT Signer attached a file '339711A4-D8C5-437D-A33A-E312CB4E0FBD.jpeg' (3.46 MB, image/jpeg)

05/15/2023 11:51 EDT Daniel Torrez (d.torrez@putlook.com) signed the document on Mobile Safari via iOS from
172.58.251.86.