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Request to Terminate or Disconnect Utility Service

  1. City of Belleview
    This request must be completed by the person(s) whose name(s) appear on the account. Identification is required.
  3. Is this a SEASONAL Disconnect?*
  4. 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.
  5. 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.
  6. Must be signed by the same person who opened the account.
  7. Code provided on account when account set up.
  8. Must match name on utility account.
  9. Must match secondary name on account.
  10. Leave This Blank:

  11. This field is not part of the form submission.