Utility Activation Authorization De-Winterization Page 4
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5UTILITY DEACTIVATION FORM
Date: ______________________
HUD Case #: ____________-_____________________________
Inspection Completion Date:
_______________________________________
Confirmed Water Shut-off Date:
_______________________________________
Confirmed Electric Shut-off Date:
__________________
*N/A if sump pump present
Confirmed Gas Shut-off Date:
_______________________________________
I have contacted all of the utility companies for which service was connected to perform the home inspection. I have
instructed each of the utility companies to disconnect service, and have confirmed the shut-off dates above.
___________________________/___________
___________________________/___________
Purchaser Signature/Date
Agent Signature/Date
______________________________________
______________________________________
Print Purchaser Name
Print Agent Name
Page 4
CONTACT A2Z FIELD SERVICES: 1-877-342-1068 (OPTION 2)
Revised 5/26/16
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