No longer responsible for water bills

Title: * Mr Mrs Ms Master Miss Dr Rev

First name: *

Surname: *

United Utilities account number: You can find this on your water bill

Please indicate your preferred daytime number: * Home Work Mobile

Telephone (Home):

Telephone (Work):

Telephone (Mobile):

Email:

House name/number: *

Flat name/number (if applicable):

Road/street name: *

Town:

City:

County:

Postcode: *

Date that you ceased to be responsible for water bills at this address: * Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2005 2006 2007 2008 2009 2010 2011

Meter Serial No. (if known):

For household customers your meter will have 4 or 5 digits on a black or white background, followed by 2 or 3 in a red background. Include all the numbers on the black or white background and ignore all the red ones

Please supply the final meter reading (if the property had a water meter):

Name of person now responsible for water bills at this address (if known):

Title: Please select... Mr Mrs Ms Master Miss Dr Rev

First name:

Surname:

House name/number: *

Flat name/number:

Road/street name: *

Town:

City:

County:

Postcode: *

If you have any queries, please let us know in the space provided: