UTILITIES DISCONNECT REQUEST
(A current driver’s license is required for all disconnect requests)
The City of Troy is committed to ensuring that your information is secure. In order to prevent unauthorized access or disclosure,
we have put in place suitable physical, electronic, and managerial procedures to safeguard and secure the information we collect.
ACCOUNT INFORMATION
(P
LEASE PRINT)
Customer Name: Account No:____________________________
Business Name (if applicable):
Service Address:
Forwarding Mailing Address (for refund and/or final bill):
Desired Service Disconnection Date:
Customer’s Phone No:_________________________________ Email:_______________________________________
By submitting this form, I certify that I am the person described above and that I am submitting this form to approve the
disconnection of service in my name with the City of Troy.
Customer Signature Date
THIS SPACE RESERVED FOR OFFICE USE ONLY
Request Received By: £ Office £ Mail £ Fax £ Online £ Email £ Other__________________________________________
Deposit to be Returned: £ Electric ____________ £ Water _____________
Disconnected By:__________________________________________________ Date:______________________________________
301 Charles W. Meeks Avenue · PO Box 549 · Troy, Alabama 36081 | Phone: 334.566.0177 | Fax: 334.808.7404
Email: customerservice@troyal.gov | www.troyal.gov
click to sign
signature
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