Utility Service Disconnect Request

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NAME OF PRIMARY APPLICANT: *

ACCOUNT NUMBER: *

EMAIL ADDRESS: *

SERVICE ADDRESS: *

CITY / STATE / ZIP: *

DATE OF REQUEST:

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edit-submitted-date-of-request-year

DATE TO BE DISCONNECTED:

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MAIL FINAL BILL/REFUND TO: *

HOME/MOBILE PHONE: *

WORK PHONE:

CONFIRMATION:

I wish to have my service disconnected. *

Agree

By checking this option, I agree that I am the Primary Applicant on this account and that I am authorized to request disconnection of this account.

SIGNATURE: *

Type your first and last name here. By signing this Electronic Signature, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Supporting Documents

Utility Service Disconnect Request (18 KB)

Utility Service Disconnect Request

Supporting Documents

Contact Information