Request for Account Closure

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By completing this form, you are stating that you are the account holder of the listed account and that you wish to terminate service.
Please be aware, that if the information provided is not accurate the Town will not be able to forward you any remaining deposit left on the account after closure. Additionally, if the account is closed after the start of a new read cycle (15th) , your account will be charged for the usage for that time period. You are responsible for any fees over your deposit amount. You will not be able to start service with the Town of Leakesville at a future date, unless those fees are paid beforehand.
After finishing, please call 601-394-2383 to indicate that you have completed the form.

Name *

Phone Number *

Account Number # *

Service Address *

Date of Termination *

YYYY

Forwarding Address *

Email Address

Electronic Signature *

Submit

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