Request for Disconnect of Services

Complete the online form below or print and complete the .pdf form here and mail to PO Box address listed below.

LIMESTONE COUNTY WATER & SEWER AUTHORITY
P O BOX 110
520 S JEFFERSON ST
ATHENS AL 35612
256-233-6444

* required fields
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Today's Date:

Date of Disconnect:

Address of Service of Disconnect*:

Customer #:

Forwarding Address for Final Bill:

Driver's License Number of Account Holder:

Social Security of Account Holder (last 4 digits):

By accepting below, the customer understands there will be a final bill generated which is for service from the last billing to the date of disconnection of service.
LCWSA reserves the right to turn over any unpaid past due balance to a collection agency. If the balance is not paid to the agency or to LCWSA, this balance will be reflected on your credit report.

The connection fee paid at the time of your request for service was a non-refundable fee.

I accept:

Upload photo of Driver's License of Photo ID: