Form

City Of Leon

Application for DISCONTINUATION of utility service
Start Date of discontinuation:
Property Owners Name

First NameLast Name
DOB
Driver's License No.
Employer
Employer Phone Number
Physical address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Currently Owe
Address of service requested

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing address to send final bill

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I hereby make application to discontinuation the utility service at the address indicated, subject to the Rules and Regulations as provided by the Governing Body of the City of Leon, which can be viewed online at the cityofleon.org. I further state that I understand I am responsible for any charges still due to the City of Leon for any previous utility bills.
Signature
Date

MonthDayYear
Date
Should be Empty:

City Of Leon