Request for Service Disconnect/Transfer NOTE: Fields marked * are required. Termination or transfer of service can only be requested by the account holder due to privacy policies. In the event of the account holder's incapacitation, death, or a change of business ownership, legal documentation is required to prove that a person requesting termination or transfer of service is the legal representative of the account holder. Requests for disconnection or transfer of electric service received at the beginning of the week may be completed within the same week under normal circumstances. Member Information *Member Name: Please enter the name of the Designated Representative on File (if applicable). Designated Representative: *Email Address: *Transfer or Disconnect?: Transfer Disconnect *Effective Date of Transfer or Disconnect: Service Address: Account Information *Member Number: Account Verification: Please provide either the last four digits of your Social Security Number or your Federal Tax ID Number. Last 4 digits of SSN: Federal Tax ID Number: For transfer or disconnection, select either all meters on the membership or only certain meter(s) on the membership that are listed below. *Disconnect all or only listed meters?: All Meters Only the Meters Listed Meter 1: Meter 2: Meter 3: Meter 4: Meter 5: Meter 6: Forwarding Information for Final Bill *Forwarding Address: *Forwarding City: *Forwarding State: *Forwarding Zip Code: Member Acknowledgement and Authorization I authorize Medina Electric Cooperative, Inc. to disconnect or transfer my electric service for the account and meter(s) listed by the effective date indicated above. I understand my request will be processed when all paperwork and/or fees are received by Medina Electric. I understand I am responsible for any outstanding account balance(s) for the aforementioned membership and meter(s) and agree to pay all outstanding balances owed to Medina Electric by the bill due date. Click here to draw your signature. Authorized Signature With your mouse, draw your signature. Then click Finish. *Name: *Date: (MM/DD/YYYY)
