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2. Name on the Account (only account holder may request to stop service)
4. First Name*
5. Middle Initial
6. Last Name *
8. Address Where Service is Being Stopped*
9. Apartment number (if applicable)
11. City*
12. State*
13. Zip Code*
15. Are you selling this property?*

    1. Yes
    2. No
16. If yes, when is the closing date?
    If yes, when is the closing date?
18. What date do you need service stopped?*
    What date do you need service stopped?
20. Forwarding Address
22. Address*
24. City*
25. State*
26. Zip Code*
28. Phone Number*
29. Email *
31. Acknowledgement

    Submittal of this application indicates agreement to allow the City of Ankeny to stop service at the above address on the date entered on this form. 

    Note: Phone number is required so we may contact you if we have questions. 

33. I understand and acknowledge the statement above.*

    Type first and last name to sign digitally.

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field