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Disconnection Request Form
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Steps
1.
Service Address for Disconnection
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2.
Customer Information
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3.
Additional Information
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4.
Customer Confirmation
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Service Address for Disconnection
**Service ONLY Monday - Friday 8:00 a.m. - 4:00 p.m. 24 HR notice required. No Service on Holidays!**
Street Address
*
City
*
State
*
Zip Code
*
Account Number
*
Date to be Disconnected
*
Date to be Disconnected
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Customer Information
Customer Name
*
Date of Birth
*
Last 4# of Social Security or Tax ID Number
*
Phone Number
*
Email Address
*
Scanned Picture of Government ID
*
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Additional Information
Forwarding Address
*
City
*
State
*
Zip Code
*
Landlord Status
Please keep my Landlord Account status
Please remove my Landlord Account status, as I have sold the property
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Customer Confirmation
I understand that my services will be Disconnected on the day that I have requested. Utility Billing does not schedule a time, therefore, services can be disconnected at any time of that service date (This includes mornings). If water is still needed at any point on that day, it is advisable to request the next available date.
*
I understand
Electronic Customer Signature
*
Today's Date
*
Today's Date
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