1

Date Service to End:

 *

MM/DD/YYYY

2

Account Name

 *

Account Name

3

Account Number

 *

Account Number

4

Phone Number

 *

Phone Number

5

Service Address

 *

Service Address

6

Are you the owner of the property?

 *

Are you the owner of the property?

Yes	No - Please List Landlord's Name If other, type text here.

7

Have you sold the property?

 *

Have you sold the property?

Yes - Please list new owner. If other, type text here.

No

Not Applicable

8

Forwarding Address

 *

Forwarding Address

Street / PO Box

City, State, Zip

**Deposits on file will be applied to the final bill first and then a check will be mailed to this address.

9

The undersigned customer requests that their utility services from the City of Yankton are to be discontinued as of the requested date listed above.  I will be responsible for all bills and charges at this service address until the requested disconnection date as listed above.

I Agree

10

Printed Signature

 *

Printed Signature

11

Date

 *

Date

12

Attach a copy of your drivers license here:

 *

Attach a copy of your drivers license here: Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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