Disconnect from Utilities

2. Service Location Address*
4. Utility Account Holder Name*
5. Disconnect Date, Monday-Friday only*
   Disconnect Date, Monday-Friday only
7. Mailing Address for Final Bill*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Email Address*
16. Account Number if only Water or only Electric account
18. I authorize the City of Ashland to disconnect the utility account at the address provided on the date provided.*
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field