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Roosevelt City Request to Discontinue Utility Service(s) Form

2. Roosevelt City Request to Discontinue Utility Service(s) Form

6. Date and time to Stop Utility Service(s) with Roosevelt City:
   Date and time to Stop Utility Service(s) with Roosevelt City:

   Date and time to Stop Utility Service(s) with Roosevelt City:

7. Customer's Name

9. Contact Number

10. Street Address

14. Important
    Mailing Address Information: Must have in case customer has a refund on the security deposit so it is not returned by the postal service for the wrong mailing address.

    Mailing Address Information: Must have in case customer has a refund on the security deposit so it is not returned by the postal service for the wrong mailing address.

16. New contact number if different that on utility account

18. Forwarding Mailing Address

20. City

21. State

22. Zip Code

24. You Can Also Fax Form To:
    435-722-5000

    435-722-5000

28. Office Use Only

30. Meter

    1. Apply Deposit to final bill
    2. Transfer Deposit to Account
    3. Transfer Balance to Accountt
    4. Turn water meter Off / Terminate
    5. Meter reading only Note: Utility services has to be transferred into Landlord or new occupant’s name the same day or water will be shut
    6. Disconnect / Seasonal Customer Vacant
    7. Vacant Lots/Active Acct terminated (This applies if no one has been in home and now it will be occupied

32. Deposit Account Number

33. Transfer Balance Account Number

35. Client Number

36. Culinary Meter Number

38. Culinary MXU Meter Number

39. Reading on Culinary Water Meter

41. Secondary Water Meter Number

42. Secondary MXU Meter Number

44. Reading on Secondary Water Meter

45. Completed By

46. Date
    Date

    Date

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

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