City of Richmond Hill
P O Box 250
Richmond Hill, GA 31324
Phone 912-756-3345 / Fax 912-756-3368
Disconnection Request Form
Disconnect Date:
Account Number:
Customer Name:
Contact Phone Number:
Disconnect Address:
Forwarding Address:
Office Use Only
Date of Request:
Request Made
Walk-In:
Other:
Verified ID _________
Ending Meter Reading: