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2. Date to Cancel Service*
   Date to Cancel Service
   Note: Water services will be turned off during normal business hours on the date selected. Water service cancellations can only be accommodated on weekdays. The City is unable to cancel water service on weekends or holidays.
6. Customer Name / Account Holder
8. First Name*
9. Last Name*
11. Phone Number*
12. Email Address*
14. Account Number*
    Your account number is needed for account verification purposes, it must be in the format listed on your utility bill. For account number help, please contact 832-595-3400.
18. Service Address to Disconnect / Cancel
20. Address Line 1*
22. Address Line 2
24. City*
25. State*
26. Zip Code*
30. Forwarding Address for Deposit and/or Final Bill:
32. Address Line 1*
34. Address Line 2
36. City*
37. State*
38. Zip Code*
42. Electronic Signature*
    I hereby declare and affirm, by 'signing' my name(s) below, that I authorize the city of Rosenberg to disconnect my utility services at the service address listed above on date specified and to mail my deposit balance or final bill to the forwarding address listed above.
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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field