The City of Dahlonega requires this authorization form to be completed for termination of utility services. Please print,
complete all fields, and authorize by signing the form. Mail this form to the address above, drop it off at Dahlonega City
Hall (Monday – Friday 8 AM to 5 PM) or email to customerservice@dahlonega.gov
NAME ON ACCOUNT: ______________________________________________________________
SERVICE ADDRESS: _______________________________________________________________
ACCOUNT NUMBER: ______________________________________________________________
DATE SERVICE TERMINATED: ______________________________________________________
(MONDAY THRU FRIDAY ONLY)
PHONE NUMBER: _________________________________________________________________
FORWARDING ADDRESS: _____________________________________________________
_____________________________________________________
_____________________________________________________
If I, ______________________ fail to pay the account in full, I understand that the City of Dahlonega will take whatever
steps necessary to collect the balance on this account at my expense. I understand my security deposit will be refunded
to the account, less any monies owed, and mailed to the forwarding address above.
________________________________________
SIGNATURE
____________________________________________
DATE SIGNED
