Leesburg, GA · Lee County
Disconnection Request
This form lets an account holder request a service disconnection and provide an address for a deposit refund.
What this form is
The Disconnection Request asks the account holder to request a final bill and deposit refund and specify the date services should be disconnected. It collects the account number, phone number, account name, current service address, disconnection date, forwarding address for the refund, and signature.
Who needs it
An account holder who wants services disconnected and a deposit refund sent to a forwarding address can use this form.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This request is signed and dated without a notary; the signer just provides a signature and today's date.
How to submit this form
- 1
Download The Form
Download the Disconnection Request PDF.
- 2
Complete The Request
Enter the account and contact details, current service address, requested disconnection date, and forwarding address for the deposit refund.
- 3
Sign And Date
Sign the request and enter today's date.
- 4
Submit To The City
Submit the completed form to the city department named on it; check the city website for current contact details.
Frequently asked questions
- What information does the Disconnection Request ask for?
- It asks for the account number, phone number, name on the account, current service address, requested disconnection date, forwarding address for the deposit refund, and signature.
- Do I need a notary for the Disconnection Request?
- No. This request is signed and dated without a notary; the signer just provides a signature and today's date.
- How do I submit the Disconnection Request?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Disconnection Request doesn’t need a notary — but if you have another Leesburg form that does, a commissioned online notary can help.