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4. Instructions
   Please provide us with the service address, date you would like to have the account out of your name and an address to mail your final bill and/or refund. Please allow at least one business day’s notice to process your final request.
6. Customer # - Account Number #
8. First Name*
9. Last Name*
11. Service Address*
13. City
    Lafayette
14. State
    Indiana
15. Zip Code*
17. Primary Phone Number*
18. Email Address
20. Move-out Date?*
    Move-out Date?
    *Soonest would be next business day from today's date*
21. Tenant or Owner*
    -- Select One --TenantOwner
23. Final Mailing Address*
25. Address Line 2
27. City*
28. State*
29. Zip*
30. +Four
32. Additional Information:
Leave This Blank:


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

    This field is not part of the form submission.

36. Submit

* indicates a required field