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Request to Discontinue Service

2. Name*

3. Phone Number*

   Numbers only, no dashes.

4. Email Address*

6. Account Number

7. Date of Request*
   Date of Request

8. Date to Disconnect Service*
   Date to Disconnect Service

   Requested disconnection date must be no more than two weeks from the date of form submittal.

10. Address to Disconnect Service*

14. Please provide the City of Melissa with your new mailing address. This information will be used to mail your final bill and/or any applicable deposit refund check.

16. New Mailing Address*

18. City*

19. State*

20. Zip Code*

24. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Electronic Signature

    By signing this form, you understand that utility service will remain in your name and will be your financial responsibility until this form is submitted to City of Melissa Utility Billing.

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field