2. Disconnect Water Service
   All fields must be completed.
4. Today's Date & Time*
   Today's Date & Time

   Today's Date & Time
   All Request must be received no later than 11:00AM the date disconnection is needed.
5. Date of Disconnect*
   Date of Disconnect
   Must be Monday - Friday Only
7. Account Holder's First Name*
8. Account Holder's Last Name*
9. Account Number*
11. Disconnect Service at:*
12. City*
13. State*
14. Zip*
16. Phone Number*
17. Reply email*
19. Last 4 digits of Account Holder's Social Security*
21. Forwarding Address:*
22. City*
23. State*
24. Zip*
26. Terms & Conditions*

    I understand any deposit on the account will be applied to the final bill. If the amount of the deposit is more than what is due on the account, a refund check will be mailed to the forward address listed above. If the final bill is more than the amount of the deposit, I will owe the difference.

    1. Yes- I am the legal account holder and I agree to these terms and conditions.
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field