Application to Disconnect Service Application to Disconnect Services Please complete and review the Applicant's Statement and Acknowledgements. To finalize the service change, the party connecting service(s) must contact City Hall, unless that party is a Landlord. Applicant(s) Information Disconnect Service(s) Date: * Today's Date: * Account Name: * Service Address: * Service Address: Service Address: Service Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Phone Number: * Secondary Phone Number: Email: * Type of Service(s) Disconnection: * Electric Service Water Service Electric & Water Services Forwarding address: * Forwarding address: Forwarding address: Forwarding address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Applicant's Statement and Acknowledgements By requesting the City of Breese to disconnect utility service(s) at the above address, you agree to pay all remaining bills on or before the due date. You further agree that if the utility bill is not paid, the city is authorized to start collection proceedings. The City of Breese reserves the right to require a signed application for disconnection of utility service(s) to be submitted in person before the disconnection can take place. Customer will be subject to current rates, rules and regulations as approved by the City of Breese. Application for disconnection of service(s) shall be made in the name of the party obligated to pay for service(s). Terms of Acceptance * I understand that checking this box constitutes a legal signature confirming I acknowledge and agree to the above Statement and Acknowledgements. Electronic Signature: * Electronic Signature: First Name First Name Last Name Last Name Date: * Submit If you are human, leave this field blank. Skip back to main navigation
