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Disconnection of Services

2. 

4. Today's Date
   Today's Date

5. Disconnect Date*
   Disconnect Date

7. Account Number

11. Customer Information

13. Name on the Account*

15. Service Address *

    Elgin, Texas 78621

17. Forwarding Address*

19. City*

20. State*

21. Zip Code*

23. Phone Number

24. Email Address

26. 

28. Customer Signature*

    I understand that by typing my name above, I am authorizing the Utility Billing Department to disconnect my services on the date indicated.

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field