UTILITY SERVICE(S) TERMINATION REQUEST FORM -- This form is used to terminate utility services.

DO NOT REPORT EMEGENCIES WITH THIS FORM!

DIAL 9-1-1 FOR ALL EMERGENCIES!

Customer's Full Name (First, Middle, & Last Name)  

Customer's Social Security Number  

Customer's Email Address  

Customer's Current Mailing Address (Include City, State Zip)

Customer's Mailing Address for Final Bill (Include City, State Zip)

Day Time Phone Number  

Evening Phone Number  

Mobile Phone Number  

Utility Account Number (This number can be found on your bill; WE MUST HAVE THIS NUMBER TO PROCESS THIS REQUEST)  

Street Address for Requested Termination  

Would you like to have your water service terminated?
Yes   No  

Date for Termination of Water  

Would you like to have your Natural Gas Services terminated?
Yes   No  

Date for Termination of Natural Gas  

Prior to the termination of any services, City Hall must receive a photocopy of the Customer's Identification. Please fax the Indentification to (229) 246-8879 to the attention of the BILLING COORDINATOR.

Signature:(type in all capitals to electronically sign)  

Date