Close Your Account

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