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Water/Sewer Disconnection Form

2. 

4. TODAY'S DATE*
   TODAY'S DATE

7. FINAL ACCOUNT

9. ACCOUNT NAME*

12. ACCOUNT NUMBER*

14. PROPERTY ADDRESS*

    West Melbourne, FL 32904

16. TURN OFF DATE*
    TURN OFF DATE

    (Water cannot be turned off on weekends or holidays)

18. EMAIL

20. FORWARDING STREET ADDRESS*

22. CITY, STATE, ZIP*

24. PHONE NUMBER*

26. NOTE:
    The Post Office will not forward your bill or deposit. You must change your address with the Utility Department.

    The Post Office will not forward your bill or deposit. You must change your address with the Utility Department.

28. SIGNATURE*

    (Type your name as your signature)

29. DATE*
    DATE

31. 2240 Minton Rd., West Melbourne, FL 32904

    2240 Minton Rd., West Melbourne, FL 32904

32. Phone: 321-837-7750 Fax: 321-768-2390

    Phone: 321-837-7750 Fax: 321-768-2390

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field