Utility Disconnection Request

Today's Date

First Name *

First name (given name)

Last Name *

Last name (surname)

Service Business Name

Provide the Business Name if applicable. Leave blank for residential service disconnection.

Account Number *

The account number is available on the utility bill.

Email Address *

Phone Number *

Service Address *

Service Address

City

State

Zip/Postal

Enter the street address where the service needs to be disconnected.

Forwarding Mailing Address *

Forwarding Mailing Address

City

State/Province

Zip/Postal

Enter your new mailing or forwarding address.

Disconnection Date *

Select your preferred disconnect date. Disconnection services are only available Monday-Friday, excluding state holidays.

Disconnection Time *

11am - 12pm

4pm - 5pm

Disconnection services are available in either the morning or afternoon.

Comments

Other notes or special instructions.

Photo ID

Maximum file size: 8.39MB

Please attach a scan (image or PDF) of a government-issued photo ID. This field is required.

Full Name *

Enter your full legal name.

Signature

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