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Utility Billing Service Request Form

2. First Name

3. Last Name

5. Email

6. Phone

8. Service Address
   Please enter the current service address you would like your request to be processed.

   Please enter the current service address you would like your request to be processed.

10. Address

12. City

13. State

14. Zip

18. Type of Reqeust*

    1. Deposit Request
    2. Final Bill / Refund Request
    3. Turn Off Request
    4. Temporary Turn Off Request

    1. Name Change Request
    2. Mailing Address Change Request
    3. Transfer Service Request

20. Deposit Request

    1. Applied to bill

    1. Check

22. Final Bill / Refund Mailing Address

24. Service Turn Off Request
    Service Turn Off Request

26. Temporary Turn Off Request
    Temporary Turn Off Request

28. Name Change To:

29. Name Change From:

31. Change Mailing Address To:

33. City

34. State

35. Zip

37. Transfer Service From:

38. Date:
    Date:

40. Transfer Service To:

41. Date:
    Date:

45. Electronic Signature*

    To electronically sign this form, please type your name in the field above and use a forward slash ( / ) before and after your name. Example: /FirstName LastName/

47. Customer Service Representative

48. Date Processed
    Date Processed

Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit Submit and Print

* indicates a required field