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2. Name*
4. Phone Number*
6. Email Address
8. Disconnect Date*
   Disconnect Date
10. NOTICE*

    Please note: if your disconnect request falls on a Friday, Saturday, Sunday or holiday, your disconnect will be dated for the first working day. For suspended services requests (extended vacations or vacancy), per LMC 15.56, you will continue to be charged for stormwater, water base charge and sewer base charges. In addition to these charges, there is a $50 turn on fee once you return and need water restored.

    1. Acknowledged
12. Service Address*
14. City
15. State
16. Zip Code
18. Account Number
20. Forwarding Address*
22. City*
23. State*
24. Zip Code*
26. Reason for Disconnect*
28. Comments
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

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