Utility Service Disconnect Request

Select the type of disconnect. Check all that apply.
Provide the date the service should be disconnected.
Forwarding address MUST BE ON FILE to complete service disconnect.
Contact Number with Area Code
The undersigned hereby applies to the CITY OF DONALDSONVILLE, Louisiana, for utility service disconnect at the premises designated above and agrees that any outstanding bill will be sent to the forwarding address provided to close the account. A social security number MUST BE ON FILE in order to complete the disconnect service.