RICHFIELD CITY CORPORATION
75 EAST CENTER (P.O. BOX 250) RICHFIELD, UTAH 84701 (435) 896-6439 (435) 896-6512 (FAX)
UTILITY TERMINATION FORM
TERMINATED CUSTOMER ACCOUNT NUMBER
TERMINATED CUSTOMER NAME
SERVICE ADDRESS
REASON FOR TERMINATION
DATE CUSTOMER WANTS SERVICES
DISCONTINUED
TERMINATED CUSTOMER’S FORWARDING ADDRESS:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
SIGNATURE OF TERMINATED CUSTOMER __________________________________________ DATE__________________
OFFICE USE ONLY
FINAL METER READING ______________ DATE OF METER READING ________________
SERVICES DISCONTINUED: YES ____ NO ____
COMMENTS:
_________________________________________________________________________________________
DEPOSIT____________ REFUNDED ___________ TRANSFERRED ____________
IF TRANSFERRED, TO WHAT ACCOUNT NUMBER ________________________________________________________
IF TERMINATED CUSTOMER MADE REQUEST IN PERSON: YES ____ NO _____
NAME OF CUSTOMER MAKING REQUEST VIA TELEPHONE, FAX, OR EMAIL ______________________________________
DATE OF REQUEST ______________
SIGNATURE OF EMPLOYEE TAKING CALL _____________________________________ DATE ____________________
PRINTED NAME OF EMPLOYEE__________________________ EMPLOYEE EMAIL______________________________
PHONE # ____________________________