Kenansville Voluntary Water/Sewer Disconnect Request

Date Date * / MM / DD YYYY
Only the customer/customers whose name appears on the bill is authorized to disconnect service unless a power of attorney is presented and accompanied with a photo ID.
Is this a temporary disconnection?

Is this a temporary disconnection? Yes No

Account holder will be responsible for all other charges/fees incurred during the temporary disconnection.
Current Bill Paid?

Current Bill Paid? Yes No
Do You Have A Bank Draft?

Do You Have A Bank Draft? Yes No
For pending refunds from your deposit, please allow 4-6 weeks from your final bill date.
Customer Name
Phone Phone - ### - ### ####
Disconnections are done in the early morning (AM)

If this is not desirable, schedule for the following business day
Disconnect Date Disconnect Date / MM / DD YYYY
Account Number
Service Address
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Forwarding Address (required for final bill)
Office Use Only
Account#
Date Account Disconnected Date Account Disconnected / MM / DD YYYY
Forwarding address added for final bill by