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2. Termination of Services Agreement

   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.

4. Account Number*
5. Account Holder*
7. Service Address*
8. Phone Number*
10. Forwarding Address*

    Please note that the account will not be discontinued unless a forwarding address is provided.

12. Date of Termination*
    Date of Termination

13. Please make sure your trash receptacle is accessible for pick up. Place it in front of residence. 

15. Property is: *

    1. Owned
    2. Rented
16. If rental property, please provide the name of the landlord/property owner.
18. Owner Address
19. Owner Phone Number
21. Account Holder Signature*

    Typing your name in the space above serves as your digital signature. 

22. Today's date*
    Today's date
24. Termination of Service Acknowledgement

    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.

26. Account Holder Signature*

    Typing your name in the space above serves as your digital signature, and that you are agreeing to the the termination of service acknowledgement. 

27. File Upload - Government-Issued ID *

    Upload a copy of your valid, government-issued ID. 

Leave This Blank:


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

    This field is not part of the form submission.

31. Submit

* indicates a required field