Town of Culpeper
400 South Main Street, Suite 109
Culpeper, VA 22701
Phone (540)829-8220
Fax (540)829-8239
UTILITY SERVICES DISCONNECT REQUEST
Date to be Disconnected :_______________________________( You must choose a business day in the
future, we do not cut service off for the same day we receive this form)
Account Number: ____________________________________________________
Service Address: ____________________________________________________
Forwarding Address: ____________________________________________________
____________________________________________________
Daytime Phone Number: ________________________________________________
Comments: ____________________________________________________________
________________________________________________________________________
I (We), ____________________________________ request my services to be disconnected for the address
listed above. I have provided my forwarding address for the final bill to be mailed to.
I am aware the trash can #________________that was assigned to the address above is Town of Culpeper
property and must remain at that address. If the trash can is not onsite when on the disconnect day, I
will be charged $60 for the replacement of the trash can on my final bill.
Applicant or Co-Applicant on Account:
_____________________________ ______________________________________
Print Name Signature Date
For Office Use Only:
Verified By: ______________________________ Service Order Completed _________
Customer Service Representative
Forwarding Address Updated: _______________ Trash Cart Work Order __________
REV 09/2011
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signature
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