WMUC, SDR Form, Revised 8/12
Service Disconnect Request Form
Your deposit will be applied to your final bill. You will either receive a check for any remaining
credit or a bill for the difference. Checks take approximately 4-6 weeks to receive and will be
forwarded to the address you provide. If you do not pay your final bill or provide a forwarding
address, your bill will be forwarded to a collection agency and new service denied until the bill is
paid in full.
ACCOUNT INFORMATION (PLEASE PRINT)
Name on
Account:____________________________________________________________________
Service Address: _____________________________________________________________
Phone: ____________________________ Email: __________________________________
Social Security #: _______________________ Turn Off Date:_______________________
FOR OFFICE USE ONLY
Received By: __________________ Date: _____________
Completed By: _______________ _ Date: ____________
AVO#: _____________________________ Date Turned Off: ________________
FINAL MAILING ADDRESS (PLEASE PRINT)
Mail To: _____________________________________________________________________
Street: _____________________________________________________________________
City: ____________________ State: ________________________Zip Code: _____________
Signature: ______________________________________________ Date: ________________
