TERMINATE OF SERVICE - LCU Service Request

Account Information

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Last Name*

First Name*

Middle Name

LCU Account #*

Phone*

Identification

DL, FEIN, or ID No.*

Service Address

Note: If you cannot find your City in the dropdown below, please use this tool to find your Utility Provider

Address*

Unit/Apt #

City*

State

Zip Code*

Date Service Disconnected*

Forwarding Address

Address*

Unit/Apt #

City*

State*

Zip Code*

An electronic or manual signature is required when submitting this form. Write your name in the signature area to submit this form electronically (acceptable per Florida Statue 668.50). If an electronic signature is not possible, the form may be printed, signed and submitted in person, via FAX, or by a scanned copy sent via e-mail.

Signature*

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