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2. Utility Account Number
4. Name*
6. Service Address*
8. Forwarding Address*
10. City*
11. State*
12. Zip Code*
14. Contact Phone Number*
16. Reason for Disconnect Request*
18. Date you are vacating home*
    Date you are vacating home
20. Home Loan Closing Date
    Home Loan Closing Date

    (If Applicable)

22. Acknowledgment *

    1. I acknowledge that I am the person that completed this form and agree to the terms of this disconnect form.
24. Occupant Signature*

    Please type your name

25. Form Completion Date*
    Form Completion Date
27. Please Note

    It is the account holder's responsibility to cancel utility services with Syracuse City.  Please do not wait for a new owner to move in and sign up for services to terminate an old account.

    Credit balances less that $5.00  will not be refunded.

29. _______________________________________________________________________________________________________________________________________________

    (IF RENTING)

31. Landlord Name
33. Landlord Address
35. City
36. State
37. Zip Code
39. Landlord Phone Number
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field