Date of Request * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Account Name * Current Service Location Address * Type of Disconnect * Gas Disconnect Sewer Disconnect Gas Account Number & Meter Number * Provide your gas account number and the gas meter number. Sewer Account Number * Provide your sewer account number. Date of Service Disconnect * Provide the date the service should be disconnected. Forwarding Address * Forwarding address MUST BE ON FILE to complete service disconnect. Phone * Contact Number with Area Code Email Digital Signature * 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. Leave this field blank
