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2. City of Belleview
4. REQUEST TO TERMINATE or DISCONNECT UTILITY SERVICE
   This request must be completed by the person(s) whose name(s) appear on the account. Identification is required.
6. Date of Request*
   Date of Request
7. Account Number
8. Is this a SEASONAL Disconnect?*

   1. YES

   1. NO
10. First Name*
11. Last Name*
13. Secondary First Name (if applicable)
14. Secondary Last Name (if applicable)
16. Service Address*
17. City
18. Zip Code
20. Phone Number*
21. Date You Want Service Off*
    Date You Want Service Off
23. Forwarding Address*
24. City
25. State
27. Zip Code
31. Acknowledgement
    I am hereby requesting the City of Belleview to permanently disconnect my utility services with them at the above referenced location. I realize this means my deposit (if any) will be applied to my final billing and any refund or bill due will be sent to the forwarding address listed above.
33. 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.
35. Electronic Signature*
    Must be signed by the same person who opened the account.
36. Passcode
    Code provided on account when account set up.
38. Electronic Signature
40. Legible Copy of state issued ID*
    Must match name on utility account.
41. Secondary Account Holder ID
    Must match secondary name on account.
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field