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Only the Account Holder will have authority to disconnect/terminate service. The Account
Holder is the name listed on your Utility Bill received from the City of Chickasha. Services will be
terminated on the date listed below when a forwarding address has been property provided.
Please note that the account will not be discontinued unless a forwarding address is provided.
Please make sure your trash receptacle is accessible for pick up. Place it in front of residence.
Typing your name in the space above serves as your digital signature.
Utility accounts not paid after termination of service will be referred to a collection agency.
Customers will be responsible for any fees charged by the collection agency in addition to the
balance of the outstanding utility account.
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize the
verification of all facts and information contained in the application for termination of service.
Typing your name in the space above serves as your digital signature, and that you are agreeing to the the termination of service acknowledgement.
Upload a copy of your valid, government-issued ID.
This field is not part of the form submission.
* indicates a required field