Form Center

Disconnection Request - Water Department

2. Today's Date / Time
   Today's Date / Time

   Today's Date / Time

4. Customer Account Name

5. Account Number

7. Phone Number

8. Date to Disconnect
   Date to Disconnect

10. Service Address

12. Forwarding Address*

14. City*

15. State*

16. Zip*

18. Electronic Signature

    1. I agree

    By checking I agree, you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.

20. If a disconnection request is received in our office before 3:30 p.m., Monday through Friday, service may be disconnected same day; otherwise, it will be next business day before 5 p.m.

    If a disconnection request is received in our office before 3:30 p.m., Monday through Friday, service may be disconnected same day; otherwise, it will be next business day before 5 p.m.

Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field