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2. City of Decatur
   Utility Account Changes
4. Date*
   Date
5. Requested Change*
   -- Select One --Disconnect ServiceChange of Legal Name
7. Current Name on Account*
8. Current Service Address*
10. Phone Number
11. Email Address
15. To Final/Disconnect Service
17. Enter forwarding address
18. Date to Disconnect
    Date to Disconnect
22. To Update Legal Name or Mailing Address
24. Updated Legal Name
25. Document(s) reflecting legal name change
29. CONFIDENTIALITY REQUEST

    1. I hereby request confidentiality of my personal information by the City of Decatur’s Utility Billing Division.
31. **All Delinquent Accounts will be sent to McCreary, Veselka, Bragg & Allen, P. C. Attorneys at Law
33. Signature
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
35. I agree to the above statement and confirm that all the information on this application is true and accurate to the best of my knowledge.*

    1. I AGREE
37. Signature: First M. Last*
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field