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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.
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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