Fremont, NC · Wayne County
Disconnect Request Form
Account holders use this form to request utility service disconnection or transfer services and provide account, contact, date, and signature details.
What this form is
This form lets an account holder request a service disconnection or transfer services. It asks for the account holder’s name, account number, address, phone number, requested date, forwarding address, and signature and date. The form states that all account balances are due and that unpaid debt will be put into debt setoff for collection.
Who needs it
An account holder requesting utility disconnection or transfer of services should complete the relevant section of 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 document is signed without a notary; the signer just signs and dates the request.
How to submit this form
- 1
Download the Form
Download the Disconnect Request Form.
- 2
Complete the Relevant Section
Fill in the account and contact details for a disconnection or the transfer services details.
- 3
Review Account Balances
The form states that all account balances are due and unpaid debt will be put into debt setoff for collection.
- 4
Sign and Submit
Sign and date the form, then submit it to the city department named on the form.
Frequently asked questions
- Do I need a notary for the Disconnect Request Form?
- No. This document is signed without a notary; the signer just signs and dates the request.
- How do I submit the Disconnect Request Form?
- Submit it to the city department named on the form; check the city website for current contact details.
- What information does the form request?
- It asks for the account holder’s name, account number, address, phone number, disconnection date, forwarding address, signature, and date. A separate section asks for transfer services details.