GRANT COUNTY PUBLIC SERVICE DISTRICT PO Box 806 Petersburg, WV 26847 Phone: 304-257-2377 Fax: 304-257-9545 REQUEST FOR DISCONTINUATION OF SERVICE | DO HEREBY REQUEST THAT SERVICE BE PERMANENTLY DISCONTINUED IN MY NAME AT THE ADDRESS LISTED BELOW. Authorized Name on Account: Account #. Loc.#. Date of discontinuation: Servi __.Forwarding Address | AGREE that | will be responsible for any and all charges incurred at this service address up to and including the “DATE OF DISCONTINUATION” above. Phone Number: Customer Signature: Utility Representative: Date: "This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law." To file a complaint of discrimination write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, DC 20250-9410 or call (800) 795-3272 (Voice) or (202) 720-6382 (TDD).