Stop Service Date *

Note: All service requests are scheduled for next business day, unless a later date is provided. Disconnection will occur between 8am to 5p.m.

Account Number *

Name *

First

Last

Drivers License Number *

Last 4 digits of Social Security Number *

Service Address *

Address Line 1

Address Line 2

City

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Zip Code

Phone *

Email *

Forwarding Address Final bill will be sent to you. *

Address Line 1

Address Line 2

City

StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Reason for Terminating Service *

• Owner – Sold Property
• Owner – Renting to Tenant
• Tenant – Moving Out
• Other

If Other, please explain

By typing or signing my name below, I knowledge above information is correct and true. *

CITY OF ANTIOCH
FINANCE DEPARTMENT
PO BOX 5007
ANTIOCH, CA 94531
(925) 779-7060
(925) 779-7054 fax
service@antiochca.gov

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Email Address

Phone

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