Disconnect or Transfer Service Form

Use this form if: You are disconnecting service completely, You are disconnecting service as well as transferring your account from one service location to another.

Note: If someone else is taking over the service, you need only fill out the upper portion, making sure to check the “Disconnect Service” box, and the “Final Billing Address” portion of this form. The person who will take over the service must contact our office to apply for that service.

Email(Required)

Current Coosa Valley Account Number(Required)

Name(Required)

First Last

Current Service Address(Required)

Street Address Address Line 2 City State ZIP Code

Date Disconnection Desired (mm/dd/yyyy)(Required)

Daytime Phone(Required)

Choose Action(Required)

Disconnect Service

Transfer Service to Another Address in Service Area

Desired Date for New Service Connection (mm/dd/yyyy)(Required)

New Address for Transfer of Service(Required)

Street Address Address Line 2 City State ZIP Code

Final Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Special Instructions?

Upload Copy of Driver's License(Required)

Max. file size: 300 MB.

Notice

Please allow at least 2 business days. We do not process disconnect requests over weekends, holidays, or after 5 p.m. during the week; however, we will process your request the next business day.

Member Electronic Signature (Full Name)(Required)

Comments

This field is for validation purposes and should be left unchanged.

Disconnect or Transfer Service Form

Notice

Keep In Touch

Office Address

Mailing Address

Office Hours

Phone Numbers