CITY OF LACY LAKEVIEW DISCONNECT WATER SERVICE

DISCONNECT WATER SERVICE

CITY OF LACY LAKEVIEW
PLEASE FILL OUT THE FOLLOWING FORM TO REQUEST DISCONNECTION OF SERVICE.

THIS DOCUMENT WILL HAVE TO BE COMPLETED AND RETURNED IN ORDER TO DISCONNECT SERVICES.

WE DO NOT BACKDATE DISCONNECTIONS. ANY BILLS INCURRED UP UNTIL THE DATE OF DISCONNECTION WILL BE THE RESPONSIBILITY OF THE PRIMARY INDIVIDUAL ON THE ACCOUNT.

IF THE DATE ON THE FORM IS DATED PRIOR TO THE SUBMISSION DATE, THE DATE IT IS SUBMITTED WILL BE CONSIDERED THE DISCONNECTION DATE.
SERVICE ADDRESS:*
NAME ON ACCOUNT:*
Phone Number*
Please enter a valid phone number.
DATE OF DISCONNECTION*

MonthDayYear
DISCONNECTION DAYS ARE MONDAY-FRIDAY 7:30 AM TO 2:30 PM. DATES CHOSEN OVER THE WEEKEND WILL BE DISCONNECTED THE FOLLOWING BUSINESS DAY.
TIME OF DISCONNECTION

TIME FRAME: M-F: 7:30-2:30 Minutes

AM/PM Option
FORWARDING ADDRESS: (can not be the same as your current service address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IDENTIFICATION CARD:*

Acceptable forms of identification are:-DRIVER'S LICENSE OR IDENTIFICATION CARD-US PASSPORT OR PASSPORT CARD-MILITARY IDENTIFICATION CARD
Cancelof
Email*
example@example.com
LAST 4 OF SSN#*
Signature*

Clear
Date*

MonthDayYear
Date
COMPLETION STATUS
Should be Empty: