Termination of Utility Service

Termination of Utility Service

Service Termination Date *

Applicant Name *

Co-Applicant Name

**ENTER ACCOUNT NUMBER AS "00000000" DO NOT USE DASHES "00-0000-00" **

Account Number *

Service Address *

Rent or Own * Rent
Own

Reason for Termination * Rented
Sold
Other

Reason for Termination if Other

The property owner of record shall be responsible for payment of all charges. If the property is rented and the renter fails to pay the charges, the city shall submit the bill to the property owner.

Acknowledgment * Acknowledgment

Please provide your forwarding address and current contact information

New Address *

Phone Number *

I understand that by terminating my service as outlined above, that I may sustain additional charges for Water & Sewer used through the termination date.

Acknowledgment * Acknowledgment

Signature (Please Type Your Name) *

Date *

* - denotes required field