2. UTILITY SERVICE TERMINATION REQUEST

   UTILITY BILLING OFFICE

   MAILING ADDRESS - P. O. BOX 7447 FREDERICKSBURG VA 22404

   PHYSICAL ADDRESS - 715 PRINCESS ANNE STREET (CITY HALL) FREDERICKSBURG VA 22401

   PHONE - 540-372-1182 (OPTION 2) FAX - 540-372-1215 EMAIL - UTILITYBILLING@FREDERICKSBURGVA.GOV

4. Account Holder*
6. I Currently have Utility service and would like to terminate my account on*
   I Currently have Utility service and would like to terminate my account on
8. Services to terminate*

   1. Water/Sewer

   1. Garbage/Recycling
10. Service Address*
12. Mailing Address*
14. City*
15. State*
16. Zip*
18. Email Address*
19. Phone Number*

21. (NOTE: The Mailing Address, City, and Zip Code supplied above should be the address at which you would like to receive your final bill from the City of Fredericksburg.)

    By signing this form, I hereby request to terminate the City supplied utility services listed above as of the date provided. I am aware that this request must be submitted 24 hours before the requested termination date.  If requested termination date falls on a weekend or holiday, the service will be terminated on the next business day. I am aware that once this request is processed, a final prorated bill will be generated and that I, the account holder, will be responsible for that balance. If there was a deposit provided when my account was opened, I am aware that it will be applied to the final bill. If trash/recycling services are being provided, I agree to place these receptacles in an easily accessible area for the City Public Works staff to retrieve.

23. Printed Name*
24. Date*
    Date
26. I Agree*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. utilitybilling@fredericksburgva.gov
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field